THE BARIATRIC BODIES PROJECT

A Dissertation

Presented to

The Graduate Faculty of The University of Akron

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy in Sociology

Corey Stevens

December, 2018 THE BARIATRIC BODIES PROJECT

Corey Stevens

Dissertation

Approved: Accepted:

______Advisor Interim Department of Sociology Chair Dr. Bill Lyons Dr. Clare Stacey

______Committee Member Interim Dean of College of Arts & Sciences Dr. Kathryn Feltey Dr. Linda Subich

______Committee Member Dean of Graduate School Dr. Susan Roxburgh Dr. Chand Midha

______Committee Member Dr. Manacy Pai ______Date ______Committee Member Dr. Isa Rodriguez-Soto

______Committee Member Dr. Mary Triece

ii ABSTRACT

How do bariatric patients make sense of the medical, aesthetic, and moral discourses related to fat, health, and illness? How are patients’ identities shifted as their bodies change throughout the bariatric surgery process? To answer these questions, I interviewed 35 bariatric patients at various stages of their bariatric careers. I divide my findings into three chapters. First, I describe the bariatric process using Goffman’s concept of the moral career and Foucault’s ideas about discipline. The moral career of the bariatric patient proceeds through 4 stages: the pre-surgery process, recovery, the honeymoon stage, and the struggle stage. I argue that bariatric surgery utilizes two types of disciplinary technology: (1) a discursive process where patients are socialized into health behaviors and must prove themselves morally worthy of surgery; (2) an embodied process where patients’ digestive tracts are modified to punish them for straying from

“the program.” Next, I focus on the illness experience of bariatric patients. Before surgery, patients experience their bodies as chronically ill and lacking in freedom. They describe fitness and pain issues which limit their day-to-day mobility. They also count down their prescription medications as an important symbol of health and illness. After surgery, patients do not view the symptoms of bariatric surgery (such as vomiting, chest pain, diarrhea, constipation, hair loss, etc.) as illness but instead as worth it in the end, as something to adjust to, and as useful tools for weight loss. After that, I explore the relationship between health, appearance, and stigma, and how this relationship is

iii impacted by intersecting identities of race, class, gender, and age. Bariatric patients describe their often-contradictory experience of the Western aesthetic of health; bariatric patients carry a highly visible fat stigma which is believed to convey their health status, yet they often view appearance as less important than health. Even after losing weight, many patients continue to carry a discreditable identity, in part due to the visible markers of their former obese status on their bodies—i.e., loose skin and plastic surgery scars.

Finally, I tie my findings together using the concepts of obese embodied identity and bariatric embodied identity. I conclude with a discussion of the theoretical implications and limitations of this study and propose future research.

iv DEDICATION

To my mother, Kim H. Stevens

“All the good in me is because of you.” – St. Vincent, “I Prefer Your Love”

v ACKNOWLEDGEMENTS

I want to acknowledge all the bariatric patients who shared their stories with me. I am so grateful to them for their willingness to be honest and vulnerable about one of the most intimate components of their selves—their bodies. I want to thank Dr. Shannon

Perkins, whose advocacy was instrumental in allowing me access to bariatric clinic patients. I can honestly say that this research would not have been possible without her. I would also like to acknowledge Dr. Christina Rummel who was my contact on the inside of the clinic. She took time out of her busy schedule to show me the inner workings of the clinic. She was enthusiastic and supportive of my work from day one—which made recruitment go very smoothly.

I am grateful to the joint graduate program at the University of Akron and Kent

State University for giving me the space to develop my scholarship and find my voice as an academic. I want to thank all the professors who taught and mentored me as I developed my scholarship, especially Professors Clare Stacy, Susan Roxburgh, Adrian

Frech, Stacy Nofziger, Tiffany Taylor, John Zipp, Cheryl Elman, Valerie Callanan, Juan

Xi, Kathy Feltey, Stephen Webster, Kristen Marcussen, Kristen Mickelson, Richard

Serpe, Rebecca Erikson, and Manacy Pai. I want to thank the committee who approved this study and offered helpful advice: Professors Clare Stacey, Kathy Felty, Susan

Roxburgh, and Issa Rodriguez-Soto. I would also like to thank Professors Manacy Pai and Mary Triece for stepping in to complete my committee.

vi I was to especially thank Dr. Clare Stacey. Her compassion helped me succeed during a very difficult time. She taught me so much about being a teacher and a researcher. Clare was with me through the dissertation process from start to finish and I could not have asked for a better advisor, teacher, and mentor. I also want to thank Dr.

Kathy Feltey. As a teacher and a co-author, Kathy has given me space to develop as a qualitative, feminist methodologist. I truly feel that I transitioned from student to colleague through working with Kathy and the rest of the pioneer women’s project, who I would also like to thank: Cheryl Elman, Barb Wittman, and Rauslynn Boyd. As the chair of the Women’s Studies Program at the University of Akron, Kathy provided me the opportunity to gain experience teaching in the women’s studies classroom—which has expanded my feminist pedagogical praxis. More than that, Kathy has been a mentor and a friend during some difficult periods in both of our lives. For that, I am truly grateful.

I also want to acknowledge my wonderful graduate colleagues who mentored me, made me laugh, and put up with a whole lot of crying. I want to thank all the collogues who indulged my short-lived attempts at forming writing groups; their feedback helped me to develop as a writer. I want to thank Peter Barr, Marci Cottingham, Dani Jauk, Jodie

Henderson-Ross, Mike Steiner, and all the graduate students who took the time to mentor me. I’m grateful to my collogues at ABIA: Mike Steiner, Peter Barr, and Michael

Rickles, the best coworkers a public health scholar could ask for. I want to thank my cohort for being my rocks throughout this process: Will LeSuer, Rania Isa, Kristen

Santos, Brooke Long, Fritz Yarrison, Lenzy Jones, Kelsey Risman, Jackie Town-Roese,

vii and Terry Mortenson. I honestly cannot name here all of the people in this program whose friendship propelled me through my graduate career. I wish them all nothing but success in and out of academia.

I especially want to thank Will LeSuer, my most steadfast office companion and one of my dearest friends. We put together major events through frayed nerves, worked through difficult problems both in and out of work, and spent a lot of time distracting each other from our work. Everyone knew that they could count on Will to complete a delegated task or help them through a tough stats problem. He could help you navigate the bureaucracy and point you to the resource that you needed. More than that, Will would offer a shoulder to cry on if you needed one. Will is one of my dearest friends and

I hope to continue to collaborate and confide in them for years to come.

I also want to thank Jodie Henderson-Ross who has been a friend and mentor through her own transition from student to faculty. I could always count on Jodie to put things into perspective when I felt myself getting lost in the all the bullshit of the bureaucratic machine and careerist discourses. Jodie inspires me to be both bold and vulnerable in my work and life. She inspires me to not forget to prioritize my community, my loved ones, and my sanity. Jodie is the radical, brilliant institutional changemaker and community leader that we should all aspire to be. Jodie and her daughters—Mikaia and

Jahara—have brought me so much joy and inspire me every day.

I want to acknowledge the professionals and organizations who helped with the work. I participated in online support communities: The National Center for Faculty

viii Development and Diversity “Faculty Boot Camp” and alumni program, and the

“Unstuck” program provided by The Professor Is In. Both of these organizations helped give sound advice to balance my work and life and provided a community to keep moving forward through the most isolating parts of the dissertation. I want to thank

Tiffany Taylor and Isa Rodriguez-Soto for recommending these websites to me. Financial support for this project was supplied in part by the Barbara J. Stephens Dissertation

Award—no relation. I’d like to thank the graduate committee for this generous award.

Professional transcription was provided by Issac Kongo; I would like to thank him for his diligent work and his patience. I would like to thank Carmen Tracey for their skillful editing. Working with them has been wonderful and I hope to continue to work with them in the future. I also want to thank my therapist, Melissa Kovach, who helped me work through my issues with anxiety and depression and finally finish my dissertation. On that note, I want to acknowledge Lafayette College for providing me with stable income and health insurance. Link and Phalen are right: privilege and power make all the difference. I want to thank my supportive colleagues at Lafayette College, especially my chair

Professor Andrea Smith.

I want to thank my family for their support. It hasn’t been an easy road, but I appreciate you all for sticking it out with me. It truly would not have been possible without your support—especially from my father, Vernon Stevens. I also want to thank my chosen family: Michael Lambert, Kayleigh Radel, and all my other friends who have been supporting me ever since I declared I was going to get my Ph.D. when I was an

ix undergraduate at BGSU, especially those who stuck with me after I quit Facebook— that’s truly a sign of family. I want to thank my rock and my best friend, Ryan Finken.

The life we are building together means everything to me. His support has carried me through some of the most challenging issues in my personal and professional life. I can’t imagine doing any of this without him. I want to thank my Akron friend community, especially Terry and Nicky Mortensen. The Mortensens have assembled the most wonderful, weird, and “awesome” group of friends. In particular, I want to thank Caitlin

Noussias for being my woman on the inside at the library and literally saving me thousands in fines. My friends in Akron and Cleveland have been my community. Their social support has made all the difference for my health and well-being and I will love them all forever.

x TABLE OF CONTENTS

CHAPTER PAGE

I. INTRODUCTION ...... 1

II. METHODS ...... 25

III. RECONFIGURED BODIES, RECONFIGURED SELVES ...... 43

IV. FREE BUT REGIMENTED, SICK BUT HEALTHY ...... 92 V. SKIN DEEP ...... 142

VI. DISCUSSION ...... 191 WORKS CITED ...... 203

APPENDICES ...... 216 APPENDIX A. I IRB NOTICES OF APPROVAL ...... 216

APPENDIX B. RECRUITMENT FLYER ...... 221

APPENDIX C. PARTICIPANT DEMOGRAPHICS ...... 222

APPENDIX D. INTERVIEW GUIDES ...... 224

APPENDIX E. MAXQDA CODE SYSTEM ...... 232

xi CHAPTER I

INTRODUCTION

The following study is based on my interviews with 35 patients at various stages of the bariatric surgery process. I designed this study with two research questions in mind. First, I wanted to explore how patients made sense of the medical, aesthetic, and moral discourses related to fat, health, and illness. Second, I wanted to understand how patients’ identities shifted as their bodies changes throughout the bariatric surgery process. I was particularly interested in their experiences of “spoiled identity” or social stigma. This project builds off existing literature on fat stigma to better understand the experiences of bariatric patients.

In this chapter, I present the theoretical literature on fat stigma, health, “obesity,” embodiment and identity which inform the research questions for this study. This work lays a foundation for understanding the dominant health and moral discourses about fatness and the impact these discourses have on embodied identities. Next, I describe bariatric surgery and provide a state of the field describing the current social scientific research on bariatric surgery. Finally, I conclude with an outline of the dissertation.

Fat Stigma

According to Goffman (1963), stigma refers to the relational effects of a trait

which is “deeply discrediting.” Goffman describes three primary types of stigma: 1)

“abominations of the body” (p 4) such as facial deformities, missing limbs, etc.; 2) “tribal

1 stigmas” (p 4) such as long-held stigma against people from certain racial or ethnic

groups; and 3) “blemishes of moral character” (p 4) such as being an ex-convict. Fat

stigma fits under two of these categories. It would be an “abomination of the body” given

the strongly held view in our culture that fat is unattractive and even unsanitary. But fat is

also a blemish of moral character—it is widely believed that body weight is under the

control of the individual and therefore those who are fat are lazy, gluttonous, weak-

willed, less intelligent, etc. (Farrell 2011; Lewis, Sophie et al. 2006; Lupton 2013)1.

Furthermore, Goffman (1963) makes a distinction between those whose identity is discredited by stigma—meaning that their stigmatized identity is known—and those whose identity is discreditable, meaning their stigmatized identity is hidden. For fat people, their identities are always discredited because their stigma is written visibly on their bodies (Gailey 2014; Saguy and Ward 2011).

As Goffman (1963) noted, what’s important is not the stigmatizing trait itself but how people respond to the stigmatizing trait. Link and Phelan (2001) argue that stigma is about the exercise of power. Stigma is a practice of power through stereotyping, status loss, and discrimination. As I mentioned above, fat people carry a host of negative stereotypes. Furthermore, there is ample evidence that fat people experience discrimination. Fat people face discrimination in many areas including medical care, education, employment, and interpersonal relationships (Fikkan and Rothblum 2012;

Puhl and Brownell 2001; Puhl and Heuer 2009). Link and Phelan have argued that stigma

1 Some scholars have even argued that fat represents a tribal stigma (Farell 2010). Body weight is approximately 70% determined by genetics. To put that in perspective, height is roughly 80% determined by genetics (Mann 2015). This suggests the possibility of intergenerational impacts of stigma much like those that impact other groups who carry a “tribal stigma” (Ernsberger 2009). 2 is itself a fundamental cause of health and illness (Hatzenbuehler, Phelan, and Link

2013). The stigma that fat people face seriously impacts their access to resources and socioeconomic mobility (Ernsberger 2009), which in turn has a serious impact on health

(Link and Phelan 1995).

The fat acceptance/liberation movement emerged in the 1970s to combat the stigma experienced by fat people (Cooper 1998; Rothblum and Sondra 2009). From this movement arose a health-related social movement—Health at Every Size (HAES) — involving activists and health and fitness practitioners aimed at separating health from weight by promoting joyful movement and mindful eating (Bacon 2008; Bacon and

Aphramor 2014). A burgeoning field of interdisciplinary scholarship has emerged from these movements —fat studies or critical obesity/weight studies (Rich, Monaghan, and

Aphramor 2011; Rothblum and Solovay 2009). Fat acceptance/liberation seeks to combat stigma against fat people and challenge the dominance of the obesity epidemic discourse, which pathologizes and medicalizes fat bodies. I will discussion the obesity epidemic discourse and its critics in greater detail later. Of course, bodies are multiple and not all fat people experience stigma in the same ways. Bodies are constructed at the intersections of race, class, gender, and other identities (Hoel 2013). Let us briefly examine the historic and contemporary construction of fat bodies at these intersections.

Fat Intersections

Prior to the 19th century, fat was a sign of high status. Since industrialization, that discourse has completely flipped, where fat people are afforded lower status compared to their thin counterparts (Farrell 2011; Fraser 2009). In contemporary Western society, fat

3 people are considered ugly, lazy, greedy, gluttonous, unintelligent, undisciplined, dirty,

and a host of other unflattering stereotypes.

This shift had much to do with industrialization and the social upheaval brought

by changes starting in the early 20th century. First, food became more readily available and work began moving indoors and becoming more sedentary. Fat bodies were no longer an embodiment of the leisure class who could afford ample food. Industrialization also created a moral crisis around consumerism —everyone wanted to keep up with the

Joneses, but no one wanted to appear to be giving in to the amoral greed of consumerism.

As a result, thin embodiment became a sign of positive moral character —not greedy or gluttonous, but self-disciplined (Sterns 1997; Bordo 1993). It also became a sign of class status, since fatness now indicated a person had the time and resources to engage in body projects to maintain a trim physique (Farrell 2011; Fraser 2009; Stearns 1997).

Amy Farrell (2011) notes that this transition from fat bodies as a sign of high status to low status was also related to the construction of whiteness. Fat bodies became associated not only with the poor but also with recent immigrants and African Americans.

Thinness became a way of marking whiteness as morally superior to the less civilized and disciplined bodies of the poor, immigrants, and racial minorities. This connection between class, race, and weight continues today. Rates of overweight and obesity follow an economic gradient where the most class-privileged have lower body mass on average than those with less class privilege (Peralta 2003). In addition, racial minorities— especially Latinx, African-American, and Indigenous Americans—have much higher rates of obesity than whites (Williams 2012). Stigmatized people also have higher rates of chronic illness and disability (Hatzenbuehler et al. 2013; Link and Phelan 1995; Williams

4 2012), including those illnesses which are commonly associated with obesity (Bacon and

Aphramor 2014). Likewise, we continue to see classist and racist discourses in cultural accounts of obesity (Campos et al. 2006; Farrell 2011; Saguy and Gruys 2010).

The connection between gender and fat is well established in feminist research on body image and fat. Fat women have been the subject of historic and contemporary fears about obesity. Much of this has to do with the well-established connection between women’s status and their adherence to conventional beauty standards and standards of femininity, which include being petite and thin (Fikkan and Rothblum 2012; Hartley

2001; Bordo 1993). As a result, women face discrimination based on size across many areas —including employment, education, health care, interpersonal and romantic relationships, etc. —at much greater rates than men (see Fikkan and Rothblum 2012 for a review). Furthermore, concerns about childhood obesity are steeped in anxiety about women’s increasing economic and social power —where working mothers are often blamed for not taking time to prepare home cooked meals and monitor their children’s weight (Lupton 2013). While women bear the brunt of weight-based stigma, men too experience fat stigma—especially men who might be considered “morbidly” or “super” obese (Bell and McNaughton 2007). Men have some protection from fat stigma because masculinity dictates that male bodies can be large—especially if they are also athletic

(Monaghan 2008). But fat on a male body is often constructed as “feminine filth.” For example, adipose tissue on the chest is often referred to as “man boobs” (Bell and

McNaughton 2007; Gilman 2004). Even people whose gender identity is outside of the male/female binary—i.e., androgynous, non-binary, or transgender —face barriers to

5 achieving their desired gender performance when their bodies betray feminine or

masculine patterns of adipose tissue (Blank 2011).

Other aspects of identity and embodiment intersect with fat stigma. Many scholars

have argued that a disability studies framework—which seeks to destigmatize and

depathologize disability—can and even should be applied to fat people. Fat people face

many of the same issues as those with disabilities—e.g., medicalization of their bodies, stigma, troubles with the built environment, etc. (Stevens 2017; Aphramor 2009;

Herndon 2002). Likewise, many disabling conditions (for example, osteoarthritis) can be exacerbated by carrying a heavy weight (Campos et al. 2006). Many of these disabling conditions associated with fatness are also products of aging. Likewise, as people age they often gain weight (Mann 2015). Despite this, very little sociological and fat studies work on fat stigma has focused on the impact of fat stigma on aging populations. There is a great deal of work looking at body image and fat stigma among children and adolescents, which finds fat stigma negatively impacts body image, mental health, interpersonal relationships, and educational achievement (Crosnoe 2007; Crosnoe and

Muller 2004; Fikkan and Rothblum 2012; Weinstock and Krehbiel 2009).

But What about Health?

We have all heard the dominant discourse about fatness—the obesity epidemic.

We are told from our doctors that the extra pounds we put on could be sickening, even fatal--that the only way to save ourselves is to discipline our bodies to be thinner. We hear media talking heads warn us about the perils of obesity—how our expanding waist lines are burdening the health care system, and how we are poisoning our children with sugar and video games. We hear about how working moms are killing their children with

6 prepackaged food, about how our youths will be the first generation to die younger than their parents. All this is nestled between a segment on the latest fitness/diet craze and a commercial for SlimFast or Weight Watchers. We hear it from public health officials like the CDC and WHO that global obesity is killing us all. It is an irrefutable, well- documented scientific fact that the increasing body mass of the world’s population is costing huge economic resources, widespread suffering, and premature death. These are the claims of the obesity epidemic—the dominant discourse on fatness (Bacon and

Aphramor 2014; Campos et al. 2006; Kwan and Graves 2013).

However, the obesity epidemic discourse is not without its dissenters. Fat acceptance and fat studies seek to challenge the assertions of the obesity epidemic discourse and combat stigma against fat people. Fat studies scholars and Healthy at Every

Size (HAES) practitioners have reviewed studies meant to support the assertations of the obesity epidemic. These researchers and advocates reviewed and conducted research which contradict many of the key claims of the obesity epidemic (Bacon and Aphramor

2014; Campos et al. 2006; Mann 2015; Rich et al. 2011). Both HAES advocates and fat studies scholars argue that the rhetoric of the obesity epidemic does fat people more harm than good by promoting fat stigma (Bacon and Aphramor 2014). In fact, discriminatory attitudes towards fat people rose during the height of the “war on obesity” rhetoric in the early 2000s (Andreyeva, Puhl, and Brownell 2008).

Most shocking perhaps is the research on the long-term effectiveness of dieting.

To date, there is no clinical evidence which suggests that long-term dramatic weight loss is a practical solution for most people. Traci Mann (2015), a head of the Health and

Eating Laboratory of the University of Minnesota, found that roughly 95 percent of

7 dieters will gain back the weight they’ve lost and damage their metabolism in the

process. After over 20 years of research in this area, Mann concluded that dieting is

ineffective. Given the failures of traditional dieting, it’s not surprising that so many

people are seeking surgical interventions to lose weight.

Despite opposition, the obesity epidemic still remains the most dominant

discourse in public health, media discussions, and the views of Americans (Kwan and

Graves 2013). This is due in in large part to a number of powerful industries—

pharmaceuticals, medical technology, diet and weight loss industry—which hold a powerful stake in the continued definition of obesity as a health crisis. They are successful not only in political lobbying and gaining public support but also providing financial support for much anti-obesity research (Campos et al. 2006; Saguy and Riley

2005).

I’ve encountered the dominance of the obesity epidemic discourse in my own work looking at fat stigma. When I wrote my thesis on fat stigma among college students, my committee demanded that I address the issue of health. In fact, any time I present

these ideas to students or colleges I am asked some version of the question, “What about

health?” It always seemed to me that in a discussion about stigma and the resulting

effects of discrimination and status loss on their life chances, whether or not a person is

healthy is beside the point. It’s not “healthy” to carry a condition like HIV, but we still

reasonably demand that HIV-positive people shouldn’t be denied opportunities to better

their lives through education, community, and health practices. Indeed, we should

demand that people who are sick or disabled be given accommodations to account for

physical or social impairments. But in my work with fat students, I discovered that

8 bullying, discrimination, ill-fitting built environments, and internalized shame and fear all impacted students’ education, health, and well-being (Stevens 2017). These problems are not the result of some internal illness; they are the ways in which fat stigma is an exercise in power and oppression.

Grappling with the “what about health?” question led me to the study of medical sociology. This is where I learned about the power of medical discourses. Beginning in the 1800s, doctors allied through the AMA and worked to gain professional dominance over concerns of health and illness (Freidson 1970; Starr 1982), for instance by pushing out competing practitioners, such as midwives (Wertz 2013). The AMA continues to often successfully lobby against external regulation (Freidson 1970; Quadagno 2004).

However, many argue the golden age of doctoring has come to an end; especially with the advent of countervailing powers seeking to regulate medical practitioners, such as managed care and government intervention (Light 2000). Despite these countervailing powers health and medicine remain a powerful discourses in our society (Conrad 2005).

Sociologists coined the term medicalization to describe the rising definition power of medicine—that is, the power to name a condition a disease and the jurisdiction to treat said condition (Conrad 2007). Medicalization is not a neutral term; the medicalization literature represents a critique of medical power and social control, owing to its roots in

Foucauldian ideas about the medical gaze (Conrad 1992; Foucault 1973). Medicine has become a major institution of social control in contemporary society and medicalization has been on the rise since the last century (Conrad 1992; Zola 1972). Recently, social theorists have suggested that medicalization has evolved into a new phenomenon— biomedicalization. Medicalization combines with rapidly advancing biomedical

9 technologies to increase the ways the body can be modified, surveilled, and optimized

(Clark et al. 2010; Conrad 2005).

Moral entrepreneurs and experts who champion medicalization argue that

defining something as a disease can eliminate the stigma of carrying certain conditions

(Sobal 1995). After all, the sick role dictates that people who are ill cannot be held

responsible for their illness (Parsons 1951). However, medicalization is in many ways a

double-edged sword. Medicalization may alleviate stigma in some instances, but at the

same time, it individualizes and depoliticizes the conditions under its jurisdiction—which

in turn can increase stigma (Boero 2012; Conrad 1992).

Medical practitioners and industries have been working to define and treat obesity

for decades. The medicalization of fat gained momentum in the 1950s with widespread

claims that obesity was unhealthy and best dealt with through medical intervention. In the

1970s, the medicalized term “obesity” came to replace other terms for fatness such as

“corpulence” in the medical literature (Sobal 1995). In the 1998, 25 million Americans

found themselves suddenly overweight when high-ranking US health agencies adopted

the Body Mass Index (BMI) as a measure of overweight and obesity (Kwan and Graves

2013). By 2005, the cost of medical treatment for obesity in the US was 1.34 billion

dollars2 (Conrad, Mackie, and Mehrotra 2010). In 2013, the American Medical

Association officially declared obesity a disease —despite the recommendations of the counsel who had investigated the issue for a year. This decision was made, despite the

recommendations the AMA’s Council on Science and Public Health after a 1-year

2 Measured by cost of bariatric surgery and weight loss medications. I suspect that if this included other medical interventions—like physician-monitored dieting—this estimate would be higher. 10 investigation. The counsel opposed the classification of obesity as a disease, citing flaws in the measure used to define obesity—BMI (Pollack 2013).

Proponents of obesity as a disease argue that defining obesity as a disease will destigmatize the condition (Pollack 2013; Sobal 1995). Yet, despite decades of medical knowledge and technology around obesity, body fat is still very much viewed through a moral lens. Even medical practitioners (in some studies, especially medical practitioners) hold stigmatizing views of fat people (Fikkan and Rothblum 2012; Puhl and Brownell

2001; Puhl and Heuer 2009). It’s clear that moral models of obesity still hold sway over the perception of obesity as a social problem.

Boreo (2012) argues that obesity represents a “post-modern epidemic.” It cannot be fully medicalized because there is no clear pathological basis for obesity as a disease—to date, there is limited evidence of a clear environmental, genetic, neurological, hormonal, or bacterial basis for obesity. However, this lack of a clear pathology makes the construction of obesity as an illness more fluid—allowing for the diagnosis of more people into this category. Furthermore, Boreo asserts that post-modern epidemics share many of elements of moral panic. Moral panics occur during times of social and economic upheaval when a certain group is seen as a threat to the existing moral order. Fat studies scholars have argued that obesity panic intensified with the economic crisis of the early 2000s as well as other forms of social upheaval, such as the concerns about the changing role of women and immigration discussed above (Campos et al. 2006; Ortyl 2010).

In addition to the moral panic associated with obesity, health in general has become a basis for moral judgement. The rise of medicalization along with neo-liberal

11 ideas about personal responsibility have created a trend towards healthism. In the U.S., the dominant discourse about health is that it is the moral obligation of individuals to discipline their behavior to optimize their health (Crawford 1980; Metzl and Kirkland

2010). Critics of this ideology have argued that this individualizing and moralizing rhetoric ignores how social factors—such as race and socioeconomic status— fundamentally shape health and illness (Bacon and Aphramor 2014; Metzl and Kirkland

2010). Furthermore, the emphasis on individual behavior stigmatizes those who are perceived to be sick through their own amoral health behaviors (Crawford 1980; Metzl and Kirkland 2010). Anti-fat discourses carry clear healthist ideologies. An aesthetic of health is applied to fat people where their visibly fat body is believed to convey not only ill health but also moral failing (Jutel 2005).

Embodied Identities

In the contemporary literature on bodies and embodiment, some of the biggest theoretical concerns are understanding the relationship between the cultural/discursive forces which shape bodies, the material reality of bodies, and understanding the body as a subject/object (Featherstone and Turner 1995; Moore and Casper 2015). Much of the foundational literature on bodies and embodiment—especially Foucault (1973,

1978,1979, 1985) —focuses on the ways in which technology and other discourses shape the body as well as the self.

Feminist scholars have critiqued/extended Foucauldian theories of bodies— arguing that bodies are not just lumps of clay shaped by discourse (Bartket 1990; Bordo

1993). All selves are embodied—in all contexts we are all embodied subjects. We experience and process the world through the senses of our body. The body is

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simultaneously an object shaped by social forces and a subject through which embodied agents perceive and construct reality reality (Bartky 199; Budgeon 2003; Moore and

Casper 2015). Furthermore, in order to understand this subject/object nature of the body, we have to understand that the body is both discursively constructed and materially

(biologically, neurologically, physiologically, genetically, etc.) real (Bartky 1990; Moore and Casper 2015).

This bodies and embodiment literature informs this study’s exploration of the embodied self. Bariatric surgery is a biotechnology of the self—patients are not only seeking a transformation of the body but also of the self (Meleo-Erwin 2012; Morgan

2011; Throsby 2008a). Through these interviews I sought to understand embodied identity and how embodied identity can be transformed through disciplinary technology.

Bariatric Surgery

Bariatric surgery is an umbrella term for a number of different surgeries which are intended to cause weight loss by surgically modifying patients’ digestive tracks to restrict how much they can eat and how much nutrition they absorb. The earliest surgery for treating obesity was jaw wiring—forcing patients to undergo a liquid diet. This intervention was not favored by physicians since most patients regained weight after their jaw wiring was removed. Intestinal bypass surgery was invented in the 1950s followed by the development of gastric bypass surgery—the most commonly used bariatric surgery to date —in the 1960s. In 1973, the term bariatrics—from the Greek “baros” for weight and

“-trics” for cure—was first proposed and adopted by physicians interested in obesity treatment. Bariatric surgery fell out of favor after the 1970s due to concerns about the side effects (Sobal 1995). The largest organization of bariatric practitioners in the U.S. is

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the American Society of Metabolic and Bariatric Surgery (ASMBS). The ASMBS formed the Center of Excellence in 2004, which provides accreditation for bariatric programs (Drew 2008). In the last two decades, bariatric surgery experienced a steep rise in from 146,301 procedures performed in 2004 to a high of 344,221 surgeries in 2008.

Since then bariatric surgery rates have remained stable with 340,768 bariatric surgeries performed in 2011 (Buchwald and Oien 2013).

The three most common bariatric surgeries performed today are Roux-en-Y or gastric bypass surgery, laparoscopic sleeve gastrostomy, and adjustable gastric band or

“the LAP band.” Roux-en-Y gastric bypass is the most common form of bariatric surgery. In this procedure, surgeons cut away all but the top of the stomach, creating a one-ounce stomach pouch. Then the first portion of the small intestine is divided, and the bottom part is connected to the stomach pouch. In the sleeve gastrostomy, surgeons remove 80 percent of the stomach, leaving a narrow, banana-shaped sleeve of stomach.

The adjustable gastric band3 involves inserting an inflatable band over the upper part of the stomach, which can be adjusted by filling the band with saline solution through a port under the patient’s skin (American Society for Metabolic and Bariatric Surgery

(ASMBS) n.d.). The eligibility criteria for bariatric surgery—set by the National

Institutes of Health (NIH)—state that anyone with a BMI over 40, or a BMI of 35 to 40

3 Many of the bariatric patients I spoke to initially wanted the gastric band because they perceived it to be less invasive than the other surgeries, which permanently modify the digestive system. However, there has been a steep decline in the number of these procedures since information about severe, deadly side effects—including bands slipping from their original position (Buchwald and Oien 2011). The clinic in this study had stopped performing the procedure, though they continued to provide services—such as adjusting saline levels in the band—for patients who had undergone the gastric banding procedure. 14 and an obesity-related illness like diabetes or heart disease, is eligible for bariatric surgery. The majority of people who receive bariatric surgery are white, socioeconomically advantaged women who have health insurance (Martin et al. 2010;

Santry, Gilen, and Lauderdale 2005).

Social Sciences on Bariatric Surgery

Just as there has been a rising number of bariatric patients in the last decade, so too has there been a growing body of social science literature investigating bariatric surgery. In order to summarize the key findings of this literature, I’ve organized them into 6 themes: 1) discipline vs empowerment; 2) bariatric surgery stigma; 3) accounting for failure; 4) medical care institutions; 5) embodiment; and 6) gender.

Discipline vs Empowerment

Much of the social science literature on bariatric surgery is based in Foucauldian

(Foucault 1978, 1979, 1985) ideas about knowledge/power and how this surgery functions as a disciplinarily technology. For instance, Karen Throsby (2008) interviewed bariatric patients in the UK. She found patients often used the discourse of “re-birth” and

“the new me.” After surgery, patients view themselves as reborn into a disciplined embodiment. This disciplined embodiment is capable of caring for the self in terms of disciplining the consumption of food and managing bariatric symptoms. Another component of the disciplinary work of bariatric surgery is managing the potential threats to the “new me”—namely the risk of gaining weight and potential challenges to the authenticity of the new me, since people perceive bariatric surgery as “taking the easy way out.”

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The paradox of bariatric surgery is that patients relinquish themselves to control and surveillance while at the same time feeling empowered and more in control (Ogden,

Clementi, and Aylwin 2006). This is not a universal experience of disease and medical control, but seems to be a feature of biomedical shift from curing and treating disease to optimizing health (Clark et al. 2010). Whereas many encounters with reparative medicine leave patients feeling helpless in the face of biomedical control (Frank 2013; Simonds

2017). Vogel (2018) conducted field work in a bariatric clinic in the Netherlands. Vogel argues that empowerment through bariatric surgery isn’t about a neo-liberal view of empowerment focused on the individual. Instead, she argues that the processes of learning new techniques of diet and exercise, along with submitting to biotechnological control, creates a new form of empowerment that is based in creating new relationships and connections. Again, Vogel notes the paradox of control; relinquishing the self to biomedical intervention empowers the self towards self-care.

This paradox about self-care and empowerment through disciplinary control is in keeping with Foucault’s later work on the History of Sexuality (Foucault 1985). Foucault notes that disciplinary power is not always negative but can be experienced as empowering, especially in the discourse on self-care. Ultimately, Foucault argues, self- care is another form of self-surveillance. Bariatric surgery is an ideal example of how care for the self is enacted through discipline (Morgan 2011; Throsby 2008). Using

Foucault’s (1985) concept of Apparatus—“heterogeneous ensemble consisting of discourses, institutions, architectural forms, regulatory decisions, laws, administrative measure, scientific statements, philosophical, moral, and philanthropic propositions”

(Foucault quoted in Morgan 2011: 195)—Morgan lays out “the complex neoliberal

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biopolitical structures and dynamics of fat hatred (188).” Disciplinary power enacts on

the body from nowhere and everywhere at the same time (Bartky 1990). By laying out all

of the forces which stigmatize fat people, Morgan (2011) challenges the notion that

bariatric surgery is an empowering choice.

Ultimately, whether one views bariatric surgery as empowering or a form of disciplinary control has a lot to do with your view of fat. For anti-obesity scholars, obesity is a dangerous pathology and grave social problem. In this perspective it can only be positive that people have found a way to care for their body by controlling its size and shape. On the other hand, feminist and fat studies scholars like Throsby and Morgan take a more critical view of pathologizing discourses about obesity. For decades, feminists have been critical of dieting and weight loss, seeing these discourses as a part of patriarchal domination (Bartky 1990). For fat studies scholars, fat isn’t a social problem; it is a part of human diversity. The real problem from a fat studies perspective is fat stigma.

Bariatric Surgery Stigma

Bariatric surgery is a technology of stigma management (Meleo-Erwin 2012). Fat people undergo bariatric surgery in the hopes that they will be able to achieve a normative embodiment and exit the stigma of obesity (Boero 2012). However, bariatric surgery is itself stigmatized. Mattingly, Stambush, and Hill (2009) found that people continue to hold stigmatizing views of the formerly obese and that these negative views are even more prevalent when it comes to bariatric patients. Drew (2011) refers to bariatric surgery stigma as a double-stigma—patients are stigmatized because of their former fat embodiment and because bariatric surgery is often conceived as morally

17

inferior to non-surgical diet and exercise. Drew identifies three themes in media coverage of bariatric surgery: 1) medically risky, 2) extravagant, and 3) a too-easy solution to weight loss. Hansen and Dye (2018) developed scales to measure bariatric patients’ perceived and enacted weight loss surgery stigma. They found that the most prevalent form of perceived stigma stemmed from the idea that bariatric surgery is “taking the easy way out.” Furthermore, there is evidence that this stigma is internalized to some extent, with a significant number of bariatric patients endorsing the belief that losing weight through non-surgical diet and exercise is superior to weight loss through bariatric surgery.

Other studies have examined how bariatric patients manage stigma. Drew (2011) found that when bariatric patients were presented with the stigmatizing discourses about bariatric surgery from the media, they refute this stigma. Bariatric patients in these interviews presented themselves as having specialized, insider expertise into bariatric surgery and use this expertise to assert that bariatric surgery is ethical. A number of other stigma management strategies are discussed in the literature, including drawing on medicalizing rhetoric to frame bariatric surgery as a necessary medical intervention

(Drew 2011; Jose et al. 2017). One of the most common ways that patients reframe bariatric surgery is by arguing that surgery is not taking the easy way out — that is requires disciplined, hard work (Drew 2011; Trainer, Brewis, and Wutich 2017).

Selective disclosure was also a common way of managing stigma, with patients often choosing to hide their status as bariatric patients (Hansen and Dye 2018; Throsby 2008).

Hansen and Dye (2018) found that patients were most likely to use this strategy when they are preparing for surgery, in order to manage the possibility of failed weight loss.

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Accounting for Failure

Failed weight loss is a crucial part of the bariatric surgery story. Patients come to bariatric surgery after years or even decades of struggling to lose weight. Given the high rates of failure for dieting, it’s not surprising that patients feel their bodies are out of control (Mann 2015; Meleo-Erwin 2012). Throsby (2007) examined how patients accounted for weight gain prior to surgery. She found that patients drew on three discourses to resist the construction of themselves as moral failures. They argued that 1) their bodies are prone to weight gain; 2) they gained their weight in childhood; and 3) life events disrupted their attempts at weight management. Furthermore, patients are often required to demonstrate a history of failed dieting before they qualify for bariatric surgery

(Drew 2008). In the UK, patients are often asked to account for the failure of using medication to manage obesity. The patients Throsby (2009) worked with accounted for this failure by arguing that weight loss medication is degrading, dangerous, and ineffective.

Failure rates are hard to find for bariatric surgery because there are inconsistent empirical definitions of failure and success in bariatric surgery. The issue of failure and success can include complications and health outcomes but, more often than not, successful weight loss and maintenance. Bariatric surgery fares better than conventional diet and exercise in terms of long-term weight loss but, given the high rate of dieting failure, this is a low bar. One long-term study found failure rates—defined as significant weight gain—between 20 to 35% after 10 years, with patients at higher starting weights experiencing the highest rates of failure. The ASMBS defined success as successfully losing and maintaining half of “excess” weight—as defined by “normal” BMI. Boreo

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notes that this definition does not often correspond with how patients measure successful weight loss, which is most often carrying a “normal” body free of fat stigma. Depending on their starting weight, some patients might still be socially considered fat even though from a medical standpoint their weight loss would be considered successful (Boero

2012).

When it comes to attributes of failure, the bariatric medical establishment is often inconsistent. Salant and Santry (2006) analyzed the content of online bariatric advertisements. They found that narratives about successful and failed weight loss were often contradictory. Clinics used medicalizing rhetoric which attributes obesity to the environment, genetics, and other external causes. However, when surgery fails, patient behavior is most often blamed. Boreo (2012) found a similar attribution of blame in her ethnographic study of bariatric patients. She found that bariatric success was often framed as a success of biomedical technology. Once again, however, failure was blamed on patient behavior.

Health Care

Social scientists have studied a number of different aspects of health care using information gathered from bariatric clinics. Ethnographic findings have provided insight into rationing practices in the UK’s National Health Service (Owen-Smith, Donovan, and

Coast 2015). Jeffrey and Kitto's (2006) fieldwork on nurses caring for post-surgical patients provided insight into how nurses navigate complex discourses of neo-liberal responsibility, medicalization, and nursing ethics of holistic caring. Felt, Felder, and

Penkler (2017) explored how diversity practices are constructed in the medical context using data collected from 2 case studies, including an outpatient clinic for bariatric

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patients in the Netherlands. They argue that obesity clinics are particularly fruitful places to study diversity because immigrants and racial minorities are more likely to experience obesity and chronic illness4.

Like all health care, those with privilege are much more likely to access medical care. The population in the U.S. which is eligible for bariatric surgery5 has lower family income, less education, is less likely to have health insurance, and has a higher proportion of racial minorities than the general population. Despite this, bariatric surgery is dominated by more class-privileged white women (Martin et al. 2010). Moore, Cooper, and Davis-Smith (2016) interviewed 14 obese African-American men to understand their attitudes about bariatric surgery. They found that Black men did not access surgery because of financial concerns but also because of social norms about masculinity.

Embodiment

Embodiment can be tricky to study in the social sciences. The experience of physical sensations in the body is often subjective and difficult to explain (Moore and

Casper 2015). Furthermore, working across both social science and medical understandings of embodiment can lead to its own difficulties. Christensen, Hillersdal, and Holm (2017) worked as an interdisciplinary medical and anthropological team to come up with a definition of “appetite”—an embodied sensation. What they developed was an understanding of appetite as a “fractional object” that is enacted differently based on context.

4 In the U.S. minorities are more likely to be obese but less likely to access health care resources. It’s probable that there are differences between the U.S. and Dutch health care contexts in terms of access. 5 According to NIH guidelines described above. 21

After surgery, patients experience a number of unpleasant and embarrassing symptoms—pain when eating, diarrhea, vomiting, etc. Sociologists have taken a look at how these symptoms are experienced by bariatric patients. Porras (2006) conducted field observations in a bariatric clinic in Catalonia. He found that bariatric surgery is not a restorative surgery, like in conventional medicine, but rather a body reconfiguration process. Bariatric symptoms are not just “side-effects” of the treatment, but instead the body’s (dis)ability to eat large quantities of food and absorb nutrients compels patients to change their eating behaviors. Throsby (2008) also identified bariatric symptoms as part of the disciplined identity of bariatric patients. Patients had to manage bariatric symptoms not only as weight loss tool but also as a part of managing hiding their stigmatized identity as bariatric patients.

Gender6

Another important aspect of embodiment has been the focus of much research on bariatric surgery—gender. The vast majority of bariatric patients are women—75%–81%

(Jose et al. 2017; Martin et al. 2010). Many scholars find conventional explanations of this phenomenon as the results of women’s greater appearance concerns unsatisfying and simplistic. Ghai et al. (2014) surveyed Canadian patients preparing for bariatric surgery and found that women pursuing bariatric surgery endorsed more body dysmorphia, more negative quality of life related to body image, and less satisfaction with their appearance than the general population of women. What they found was that women’s sense of self was much more tied in with the control of weight and eating than men’s sense of self.

6 I discuss gender in binary men/women terms in this section. This is because most of the research focuses on men and women’s experiences. I am not aware of any literature examining queer, trans, or non-binary bariatric patients. 22

Newhook, Gregory, and Twells (2015) also found that bariatric patients drew on dominant, gendered discourses about appetite and weight. These discourses shape bariatric surgery as feminine—just like other normative feminine practices of surveillance over food and the body. Men resist these discourses, contrasting their experiences with those of women. Moore and colleagues also found that men’s attitudes towards surgery and interpersonal experience after surgery were shaped by masculinity

(Moore and Cooper 2016; Moore et al. 2016).

Layout of the Dissertation

In order to study the embodied identities of bariatric patients, I designed a qualitative, interview-based study of patients at a bariatric clinic. I provide a detailed description of my methods for data collection and analysis in chapter 2. I also provide a reflexivity statement that I wrote after data collection for this research project. Chapter 3 explores the bariatric process using Goffman’s concept of the moral career and

Foucault’s ideas about discipline. I describe the moral career of the bariatric patient in stages: the pre-surgery process, recovery, the honeymoon stage, and the struggle stage. I argue that bariatric surgery utilizes two types of disciplinary technology: 1) a discursive process where patients are socialized into health behaviors and must prove themselves morally worthy of surgery, and 2) an embodied process where patients’ digestive tracts are modified to punish them for straying from “the program.”

Chapter 4 focuses on the health and illness experiences of bariatric patients.

Bariatric patients’ experiences are shaped by discourses about health, obesity, and stigma.

Before surgery, patients experience their bodies as chronically ill (or at risk of chronic illness) —they describe fitness and pain issues which limit their day-to-day mobility.

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They also count down their prescription medications as an important symbol of health

and illness. After surgery, patients do not view the symptoms of bariatric surgery (such as

vomiting, chest pain, diarrhea, constipation, hair loss, etc.) as illness but instead

normalize these symptoms as part of the healing process, something to adjust to, useful

tools for weight loss, and worth it in the end.

Chapter 5 focuses on the relationship between health, appearance, and stigma and

how this relationship is impacted by intersecting identities of race, class, gender, and age.

Bariatric patients describe their often-contradictory experience of the Western aesthetic of health; bariatric patients carry a highly visible fat stigma which is believed to convey their health status, yet they often view appearance as less important than health. Even

after losing weight, many patients continue to carry a discreditable identity, in part due to

the visible markers of their former obese status on their bodies—i.e., loose skin and

plastic surgery scars.

In chapter 6, I discuss these findings and connect them back to the concepts of

obese and bariatric embodied identities. I also provide theoretical implications for fat

studies, medical sociology, and bodies and embodiment literature. I conclude with a

discussion of the limitations and propose future research.

24 CHAPTER II

METHODS

To better understand the experiences of bariatric patients, I interviewed them and reviewed some of the documents given to them by the clinic. This chapter details the sampling procedures, sample, data, and analytic strategy for this study. I’ve also included a description of the clinic where I recruited participants. I also give an account of my own positionality as a researcher.

Procedures

Sample Procedures

I interviewed a purposive sample of bariatric patients from a single bariatric clinic7. This clinic is situated within a major hospital chain in a city in America’s Rust

Belt. I describe the clinic in more detail below. Participants were recruited in four ways.

First, I hung flyers in two of the clinic’s waiting rooms (see Appendix II). Second, a

psychologist at the clinic took my business cards and handed them to patients she

believed would be good candidates for my study—that is, patients she felt were

emotionally healthy enough to participate in my research. From these efforts, I recruited

six participants. Third, I attended the first five minutes of patient support group meetings.

I gave a brief statement about my research and patients passed a sign-up sheet around.

The clinic holds two support group meetings. The largest meeting consists of

presentations by hospital staff on various topics such as nutrition and plastic surgery.

7 One patient had their surgery done in a different clinic, but had moved to a new city. He was using the clinic support groups, though not fully committed to becoming a patient of the clinic for follow-up. 25 Both pre- and post-operative patients attend these meetings. The smaller, more intimate

meeting is a more traditional support group meeting where patients gather to support one

another and talk through their post-surgery struggles. This meeting is led by one of the

clinic psychologists and is only open to patients who have already undergone surgery. I

attended one of these large meetings, recruiting fourteen participants, and seven of the

smaller meetings, recruiting ten participants. Finally, participants and my professional

contacts put me in touch with five additional participants. In total, I recruited 35

participants.

Sample Characteristics8

The 35 patients I spoke to were at various stages of obtaining, recovering from,

and living after bariatric surgery. Nine participants were in the midst of the pre-surgery

process when I interviewed them. Of those nine, I interviewed five a second time—four

of these patients both pre- and post- surgery. I interviewed 31 participants after their

surgery date. These patients range from one month post-surgery to 11 years post-surgery.

Most participants had undergone or were planning to undergo the Roux-en-Y

procedure, often referred to as gastric bypass surgery9. The clinic surgeons most often

recommended this surgery to patients, claiming it would produce the most dramatic

weight loss. Four participants underwent the sleeve gastrostomy procedure10. Two chose

this procedure because they believed it would be less invasive. The surgeon ordered this

8 For a table of sample characteristics see Appendix III 9 In the Roux-en-Y procedure, the stomach is reduced to a small, one-ounce pouch and the first few inches of the small intestine are removed. The modified stomach and intestines are then reconnected. 10 In the sleeve gastrectomy, the stomach is reduced to a sleeve about the size and shape of a banana. In this procedure, the intestines are left intact. 26 procedure for the other two because of concerns that the Roux-en-Y would interfere with

the absorption of their psychiatric medications. One of these women later underwent a

revised Roux-en-Y procedure when her diagnosis was changed from bipolar to unipolar

depression. Two patients had undergone the lap-band procedure11. The clinic no longer performed this procedure because it often caused complications, but continued to provide follow-up and support group services to patients who had undergone the lap-band procedure in the past or at another clinic. One of these participants had the lap-band removed and underwent the full gastric bypass procedure after experiencing these complications. The other was very happy with her band and hadn’t faced any complications.

The sample for this study resembles demographic trends that (Martin et al. 2010) found in a nationally representative sample. In terms of gender, 6 men (17%) and 29 women (83%) participated. The closely represents national trends, where women (81%) are far more likely to undergo bariatric surgery than men (19%) (Martin et al 2010).

Participants were predominantly white (83%) with 5 African-American women and one bi-racial (Black and Jewish) man (17% non-white). This sample consists of more white people than national trends (75% White, 11% Black, 10% Hispanic, and 4% other)

(Martin et al 2010). However, it is not surprising given the demographics of the area

(77.9% White, 14.1% Black, 2.9% Asian, 2% Hispanic) (URL: https://datausa.io/profile/geo/akron-oh/#demographics). At the time of their interviews,

11 The lap-band is an inflatable band placed around the stomach and filled with saline solution to produce the desired restriction. 27 participants in this study ranged in age from 29 years old to 75 years old, with the

average age of 53.5 and median age of 54.

I collected three measures of socioeconomic status (SES): occupation, education,

and health insurance. Occupation can be a problematic measure of SES, especially in a

sample of people who largely (40%) don’t have a formal occupation. Many of my

participants were retired (26%), disabled (9%), full time caretakers (5%), or students

(n=1). Of those who worked, about 15% worked in blue collar jobs, 38% worked white

collar jobs, and 7% had professional careers12. Education can provide a better measure in

this case. Among this sample, 8 participants had high school diplomas or trade school

(23%), 5 associate’s degrees (14%), 9 had attended some college (26%), 8 had completed

4-year college degrees (23%), and 5 participants had (or were seeking) professional or

master’s degrees (14%). In terms of insurance, only one participant was uninsured at the

time of her first surgery, although for her second surgery she was insured through

Medicare. 31% of participants relied on government insurance (i.e., Medicare and

Medicaid) and about half of these participants also had some form of private or

government supplemental insurance as well. The majority of participants (68%) were

privately insured. 14% paid for private insurance and 54% of participants were insured

through work or a family member’s work. From these measures, there is a greater amount

of SES diversity among this sample than in the general bariatric population. Martin et al.

12 Interestingly, approximately half of the sample worked in the health care industry – at all levels including a doctor, administrators, nurses, a raspatory therapist, janitor, a home health care worker, and nurses aids. This is certainly due in part that many workers in the health care system where the clinic is located have insurance which covers bariatric surgery. I also suspect that people who work in health care are more likely to accept medicalized solutions to their embodied concerns. 28 (2010) found that 82% of the bariatric patients were insured through private insurance,

whereas this sample is only 68% privately insured with an overrepresentation of

Medicare and Medicaid patients. This could be due in part to the more advanced age of

many patients in this study.

I conducted in-depth interviews with participants between January and September

of 2015. Because my recruitment was concentrated in one hospital clinic, participants

were concentrated around Northeast Ohio. Interviews were conducted in person, either at

the home of the participant or in a public place of the participant’s choosing, including

hospital waiting rooms, libraries, restaurants, coffee shops, and a room in the University

of Akron. Most interviews were conducted one-on-one with a few exceptions. I

interviewed two participants who were friends at the same time, and two participants

brought a support person to interview with them—a sister and a wife. Participants were

given an informed consent form to sign and indicate if they were willing to be contacted

for a follow-up interview; all indicated that they were. This consent form was approved

by the University of Akron’s IRB (see Appendix I).

For these interviews, I constructed open-ended interview guides designed to elicit

stories about the participants’ experiences as patients, changes in their bodies, and how

others responded to their decision to undergo surgery as well as their changing bodies. I

quickly realized that a one-size-fits-all interview guide was not going to work for patients at various stages of bariatric surgery. Therefore, I constructed a guide for patients who were pre-surgery and patients who were post-surgery. Later, I developed a third guide for patients I had interviewed pre-surgery who were now a month to three months post-

29 surgery (see Appendix IV for guides). I modified my guides as patterns and themes began to emerge in these interviews (Charmaz 2006).

I designed my interview guides to elicit stories about participants’ experiences as patients of a bariatric clinic and how these processes made them feel. I asked patients to describe their bodies before and after surgery to understand how patients experienced their changing bodies. I also asked questions to understand patients perceptions of other people’s responses to a patient’s decision to undergo bariatric surgery and their changing bodies and needs. Interview guides are available in Appendix D.

Interviews lasted between 22 minutes and 3 hours. Most interviews lasted about an hour and 15 minutes with the median length being 73 minutes and the average length being about 79 minutes. Five participants sat for an interview two times, usually before and after their surgery—with the exception of one participant who sat for two pre-surgery interviews. I transcribed a six interviews, the rest were transcribed by a professional service. This study was funded in part by the Barbara J. Stephens Dissertation Award conferred by the University of Akron Department of Sociology.

Auxiliary Documents

While interviews were the primary source of data, I also collected some documents the bariatric clinic provided to all patients. These documents reflect the culture and mission of the clinic and can provide clues as to the sorts of values the clinic holds (Altheid and Schneider 2013). One of my participants was kind enough to allow me to make copies of her “New Patient Manual,” a document all new patients receive that outlines the basics of the program and the surgeries the clinic offers. She also allowed me to copy the large binder given to bariatric patients before they undergo surgery, entitled

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“Reclaim Your Life: Patient Education Manual.” Participants referred to this document as a “bible” for bariatric patients and many patients mentioned that they kept it and referenced it often as their patient career progressed.

Analysis

I transcribed a few of the interviews, but most of the transcription was completed by a third party who signed a confidentiality agreement13. I coded the interview and document data using MAXQDA 11/12 software. I initially open coded for larger themes, keeping in mind my interest in the medicalization of fat and patients’ experiences of stigma. I chose a few themes which emerged during the interview process and through open coding to write the three empirical chapters of this dissertation (i.e., chapters 3-5)14.

First, In interviews, I asked patients to describe the process of obtaining, recovering from, and life after surgery. I quickly realized that this surgery was not simply a medical procedure but a life-long moral career. The initial categories of “Dieting

Stage,” “Pre-Surgery Process,” “Surgery and Recovery,” and “Life After Surgery” emerged during data collection as important stages in bariatric patient careers. I added these stages to my codebook for initial coding. During refined coding, I went back through these codes and looked for patterns within each stage. I have detailed the ideal types which emerged from this coding process in chapter 3.

13 I found this third party through a colleague. This individual lived in Kenya and so when I reviewed his transcripts, I had to fix a few translation issues. Common colloquialisms used in the United States didn’t translate well to an English speaker in Kenya. For instance, anytime a participant said “mom,” the transcriptionist wrote “mum.” 14 For a complete list of codes used to analyze this project see Appendix V 31

Second, I coded patients’ accounts of health during open coding. During refined

coding, several patterns emerged15 and I chose to focus on three: 1) mobility and fitness

issues, 2) counting the number of medications one takes as a sign of health and illness,

and 3) symptoms and complications resulting from surgery. All of these codes were

frequently found in patients’ accounts of their subjective experiences of health and

illness. My finding for patient experiences of health and illness are detailed in chapter 4.

In a personal conversation with a colleague who had undergone bariatric surgery,

I noticed that they emphasized that health should be more important than appearance for

bariatric patients. I realized that this idea that health was morally superior to appearance

was something that came up in my interviews with bariatric patients a number of times.

However, I had also noticed that appearance was really important to many patients—

especially women and young women in particular. I thought and memoed about this

issue. During open coding, I coded for mentions of appearance and stigma. During

subcoding, I looked for places where appearance codes and health codes overlapped. I

quickly noted that both health and appearance were also related to morality and stigma.

Through refined coding I also noted unique patterns within different, intersecting

identities of class, race, gender, and age. I detail these findings in chapter 5.

Context: The Clinic

This study centers around one bariatric clinic situated within one of two major

hospital systems in a large Rust Belt city. The clinic is located on the far end of the main

medical campus for this system and is connected to their general hospital and other

15 I also collected some really fascinating data on the use of medicalized terms and the meaning that patients place on the word “obesity.” I will develop these into another book chapter or journal publication at a later date. 32 building through a series of parking lots and bridges. The clinic has a large staff of three

surgeons, two dieticians, two psychologists, and a number of other doctors, nurses, and

support staff. I gave the name of my contact—a clinic psychologist, Dr. Young16—at the front gate. The attendant looked at me with confusion, so I told her I was here for the bariatric clinic. She informed me that in the future I should “just say Bariatric Care. They have so many doctors they don’t even give me a list.”

Upon entering the building, I was first struck by how beautiful it is. The glass doors open on an entryway. On the left is a large green marble staircase with a fountain full of coins built onto the side. Directly ahead are a series of elevators with large brass doors. Further down the hall past the staircase there is a Starbucks, a Subway restaurant, and a small waiting area with a television. On the right there are several large windows looking in on the waiting room for the endoscopy procedures. But when I looked up, I noticed a waiting room at the top of the stairs where the windows are opaque with a green and brown pattern of leaves. This is the waiting room for the bariatric clinic.

I climbed the stairs and entered the waiting room for the bariatric clinic. The first thing that struck me was how large the chairs were in the waiting room. Some had armrests and some did not, but nearly all were 2 or 3 times as wide as the standard waiting room chairs. Everything in the space communicated an awareness of the needs of larger bodies and the stigma bariatric patients experience as fat people seeking bariatric surgery. The windows are opaque to prevent patients from feeling exposed to anyone

16 The names of participants, contacts, locations, and providers have been changed to protect the privacy of participants. 33

entering or leaving the building. The large chairs, Dr. Young informed me, were specifically chosen to help patients feel less stigmatized.

When I entered the room, a fat white woman in scrubs greeted me through the window to the nurses’ station. I told her I had an appointment with Dr. Young. She smiled and told me to sign in and have a seat. Before I could clarify that I was not a patient, a voice from behind the nurse exclaimed, “She’s not a patient! She’s a student here to talk with me.” She told me she would be with me in a moment. A minute later,

Dr. Young emerged from the door smiling and shook my hand. She is a slender young woman approximately my own age (late 20s to early 30s).

She showed me to her office and invited me to sit. She sat down in a standard office chair at her desk while I sat in a chair almost big enough to be considered a love seat on the opposite side of the room. I found it easy to connect with Dr. Young. We talked about our experiences writing dissertations as graduate students. She had just finished a post-doc and was only a few months into her new position as a psychologist at the clinic. I told her about my study and we discussed some ways she could help me recruit participants. She said that her dissertation was on LGBT people in grad school and so could empathize with trying to study a hard-to-reach population.

I later learned that Dr. Young faced some challenges replacing her predecessor who was well liked by patients, especially those who attended the small monthly support group for post-surgery patients. Her predecessor had agreed to allow me to collect data at support groups, assuring me that graduate students sat in on these support meetings frequently. But by the time I had processed my study proposal through IRB, she had left the clinic to work elsewhere in the hospital. Dr. Young had less institutional knowledge

34 and so I had to renegotiate my access to the clinic—which did not include collecting field notes at the support group meetings.

Dr. Young showed me around the offices. I noticed that all of the offices had at least one of these extra-large chairs for patients. The clinic occupies two floors of offices and conference rooms and a second smaller waiting room. The office space was busy and crowded. Some of the spaces were being renovated to make more room for staff and providers, which meant that many desks were crammed into the hallway in disheveled- looking cubicles. Dr. Young tried to introduce me to the office manager, but she was far too busy to speak with me. Even the woman at the reception window in the second waiting room was running around almost frantically.

Next, Dr. Young walked me across two buildings connected by bridges and down an elevator into the basement rooms where the support groups meet. These rooms were clearly purposed for other meetings and banquets. You could smell and hear the kitchen and there were buffet tables set out for an upcoming event. I commented that it seemed a little strange to hold bariatric support group meetings in a space where you could smell food. Dr. Young agreed and told me she was trying to move the support group to a classroom in the clinic—which she was later able to do. However, the second, larger support group for pre- and post-operative patients still meets in those basement rooms.

According to the patients I spoke to, the quality of care at the bariatric clinic is excellent. With few exceptions, most participants spoke of the staff and the clinic in glowing terms. The materials given to patients list the names and numbers of many key members of the staff and encourage patients to call if they have any questions or concerns. Patients reported that they were frequently encouraged to call by staff and

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practitioners. Some of the more advanced patients reported that their callback time had increased since the clinic has been taking on many more patients. However, most reported that they were satisfied with the care they received. In spite of the frantic activity backstage at the clinic, staff and doctors were often described as acting very warmly and positively towards their patients. This is crucial when you consider how often fat patients experience stigma in medical settings (Fikkan and Rothblum 2012; Puhl and Brownell

2001). Furthermore, patients often said that in spite of some of the frustration of waiting to obtain surgery, they appreciated how comprehensive the bariatric program was in assessing them before surgery and providing medical, nutritional, and psychological education and support.

Positionality Statement

My scholarship is informed by feminist methodological practices which demand that we should be reflexive about our own standpoint within systems of power (Collins

1991; Harding 1991; Smith 2005) and our embodiment (Sherif 2001; Reich 2003; Fonow and Cook 2005; Ellingson 2006; Throsby and Evans 2013; Hoel 2013) as part of the research process. My experiences as a fat, white, young, college-educated woman play an important role in this work in many ways. First, as researchers we often “start where we are” (Lofland et al. 2006). My experiences as a fat person have inspired me to research fat bodies in the medical setting. Second, working with these patients has challenged my views as a fat studies scholar and caused me to acknowledge some of my own privilege as a young, able-bodied person. Third, I discuss some of the ways my own fat body impacted the research.

36

My interest in bariatric surgery stems from my own experience as a fat woman.

I’ve been much larger than most of my peers for as long as I can remember. I’ve been bullied, abused, and harassed for my weight. Sadly this is a common experience for fat youth (Weinstock and Krehbiel 2009), especially women and girls (Fikkan and Rothblum

2012). Through my work in college as a feminist activist and burgeoning scholar, I came into contact with the ideas of body positivity, fat acceptance, and Health at Every Size

(HAES). These philosophies helped me to heal from some of the trauma and internalized shame of growing up a fat girl in a fat-phobic culture. Furthermore, it ignited my intellectual curiosity and drove me as an activist-scholar (Throsby and Evans 2013).

At 5 feet 6 inches tall and approximately 276 pounds, my BMI of 43.2 puts me well within the range of “morbidly obese.” While I have a high BMI, I am otherwise a healthy 29-year-old woman. My blood pressure is stellar and aside from some stomach acid issues, which I manage with diet and over-the-counter medications, I do not have any obesity-related diseases. Like most college-educated people, I do often treat my body and health as a project (Williams 1995). I’m a fairly active person who enjoys yoga, hiking, and strength training. I strive to stay active and get in as many healthy fruits, vegetables, and vegetarian proteins as my busy, low-wage student life will allow. I strive to practice the tenants of HAES and live what Mann (2015) refers to as “my lowest livable weight.”

My work with fat scholarship started with my thesis work on fat college students.

I was interested in how fat college students experienced and resisted fat stigma and how these experiences were shaped by gender. Initially, I was not interested in fat people and health. In fact, I actively pushed back against the refrain of, “But what about health?” My

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feeling was that it didn’t matter if fat was healthy or not, no one deserved to be treated

like a second-class citizen because of their supposed health status. Through this research I

learned that the connection between weight and health was contested by HAES advocates

and other scientists (Bacon and Aphramor 2014; Campos et al. 2006; Mann 2015).

This sparked my interest in medical sociology. Why are the dominant discourses

about medicine and health so powerful and pervasive in this debate? Why are issues of

health and illness so effective in stymieing debates on anti-fat discrimination (Saguy and

Riley 2005)? Perhaps most important to this study, what effect do these medical

discourses have on the day-to -day lives of fat people? I figured what better place to study

the power of these discourses and their impact on fat bodies than to study people

undergoing medical interventions for their fat bodies—such as bariatric surgery.

Over the course of my work, I came to understand bariatric surgery differently. I

initially proposed this study feeling, as many fat acceptance activists do, that the practice

was terrible—that it left people maimed and mutilated. I envisioned legions of people

sick and full of regret. The first change in my thinking occurred after reading other social

scientific work on bariatric surgery. I soon became aware that bariatric patients

experience stigma not only because of their fat bodies, but also because bariatric surgery

itself is stigmatized (Drew 2011). Reading about this “double-stigma” made me realize

that I needed to be reflexive about my own stigmatizing views of bariatric patients. I

needed to put aside my notions of bariatric patients as cultural dupes or desperate, self- loathing, passive victims of fat-phobic culture and start to see them as agents (Throsby

2009). I needed to be open to understanding bariatric surgery from their perspective and check my own assumptions about this experience (Hoel 2013).

38 My second revelation came later as I continued to consider a question that commonly came up with this research: is bariatric surgery something I would do? I am in many ways an ideal candidate for the surgery (Boero 2012). With a BMI of 43.2, I qualify for the surgery without any other obesity-related conditions. As I mentioned above, I am young, healthy, able-bodied, and active, meaning I would likely recover quickly from surgery. My status as a person of considerable size made me a partial insider, which comes with its own advantages and pitfalls in terms of gaining rapport in the field (Sherif 2001).

This question was much tougher to navigate when it came up in the field. I didn’t want my participants to know my true feelings about the surgery for fear that they would feel stigmatized and not share intimate information or negative experiences. The first time I flubbed it. A participant asked me if I was considering it. Reaching for something to say, I told her I qualified and that my family thought I should do it. All true, but I didn’t feel good about giving her the false understanding that I was seriously considering it. She was the first of a small but vocal group of participants who told me why I should get the surgery. This often led to some good data but stressful social interactions. I later discovered that my insurance did not cover bariatric surgery and that became my response when participants told me I should get surgery.

In listening to patients’ stories, I discovered that many came to surgery very sick.

Many had disabilities that were exacerbated by their weight or experienced crippling joint pain caused by their weight. Many had diabetes that was becoming increasingly difficult and expensive to manage. For many patients these illnesses and disabilities abated and even went into remission after their surgery. Listening to their stories made me realize

39 how privileged my previous stance on bariatric surgery was. I often use my own status as a healthy, able-bodied, active, young person to ward off stigma associated with my weight. It’s easy for a person like me to say that bariatric surgery is something they would never do or is fundamentally wrong. However, it would be hubris to assume that my youth and health will remain forever. Diabetes and crippling arthritis run in my family. Who am I to say there will never come a point in my life when this surgery won’t seem like the only option?

My fat body presented several methodological opportunities and challenges. I completely effortlessly blended in at that bariatric clinic. People did not often ask me what I was doing there, as most assumed I was there as a patient. This presented an ethical dilemma in some instances because I was not trying to go stealth or be deceptive in my research. However, I sometimes found myself in situations where people did not realize they were talking to a researcher. I tried to rectify this by correcting people’s assumptions as quickly as I could, but it still left me concerned about how best to treat the data I collected from participants who did not fully realize who I was.

I also believe that my fat body was an important tool for gaining rapport with participants. It was not uncommon for participants to say things about how people who are not fat often “don’t get it”—specifically how difficult it is to lose weight and maintain that weight loss. I was also able to use my own experiences with dieting to gain rapport. I would often share my own experience losing 80 pounds on the Adkins diet and then gaining back over 100 pounds, or my mother’s experience of having her gallbladder removed because of the same diet. Not uncommonly we would talk about a particular diet or fitness app that we both had used.

40 Doing this research took a toll on my own body image and eating behavior in ways I did not fully anticipate when I started this research. As Throsby and Evans (2013) assert, much feminist methodological theory has focused on the effects of the researcher on the participants, but relatively little has looked at the impact of the research on the researcher. There is a culture of cowboy ethnography that does not take into account how vulnerable our embodiment may cause us to feel under certain circumstances (McKinzie et al. 2015).

I have come a long way in terms of accepting my body and even have positive feelings about it. However, this has not always been the case and I have engaged in many efforts to lose weight. Listening to participants discuss their own experiences of bodily shame and ongoing efforts to lose weight retriggered a lot of these food-related issues. I went on a diet during my data collecting. I exercised every day and went down to a

1,200-1,500 calorie diet for several weeks. I snapped out of it after reading Dr. Traci

Mann's (2015) book, Secrets from the Eating Lab. Mann carefully lays out all the evidence from 20 years of her research on dieting. She concludes that dieting is ineffective and bad for your health – especially weight cycling like most chronic dieters do, myself included. It made me realize how miserable I was making myself and how dieting was impacting the quality of my work.

I quickly realized I needed to strategize how to deal with my own concerns about body image while working on this research. Following Mann’s advice for living “your lowest livable weight” and HAES, I’ve attempted established ways of engaging in the body-as-a-project health goals that are popular among class privileged people (Williams

1995) without compromising my mental health. I try to focus more on fitness goals that

41 reflect what I can do and how I feel rather than my body weight. I set rules forbidding myself from counting calories or even looking at a scale during my work on this dissertation. However, I do cheat and check the scale from time to time.

42 CHAPTER III

RECONFIGURED BODIES, RECONFIGURED SELVES

THE DISCIPLINARY CAREER OF THE BARIATRIC PATIENT

In this chapter, I examine the bariatric surgery process as a disciplinary technology (Foucault 1979) and a moral career (Goffman 1961) designed to shape patients’ embodied selves. Specifically, through the disciplinary career of bariatric surgery, patients transition from an obese embodied identity to a bariatric embodied identity. The bariatric clinic utilizes two types of disciplinary technologies. The first is a discursive process where patients learn diet and exercise techniques. It is also a moral process, where patients learn to judge themselves and others by how closely they adhere to the self-surveillance techniques involved in “following the program.” The second disciplinary technology is an embodied process. The surgery itself reconfigures the digestive tract so that the body craves less food and punishes the patient for eating too much or certain kinds of food. The two processes are interrelated, as the disciplined bariatric embodied identity is focused on surveillance of the body, while the body responds to and resists its reconfiguration.

The moral career of the bariatric patients begins long before they ever set foot in the clinic and continues long after undergoing the surgical procedure. I organize the moral career of the bariatric patient into pre-surgery and post-surgery periods. I break the period before surgery into two stages: the dieting stage and the pre-surgery process. Life after surgery breaks down into three phases: the recovery, “honeymoon,” and “struggle” stages. I describe each of these periods in terms of the disciplinary techniques used by

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patients and clinic staff as well as the changes in the embodied self which result. I argue that over the moral career of the bariatric patient, the patient transitions from an obese embodied identity to a bariatric embodied identity.

Theoretical Background

Foucault: Disciplining the Body

To Foucault, knowledge (or “discourse”) is an exercise in power—especially sciences that seek to know (and control) human bodies and behavior (Foucault 1995).

Knowledge and power are one and the same—knowledge/power (Foucault 1984).

Foucault’s work is useful in understanding how institutions enact knowledge/power to control people by disciplining them to govern themselves—turning them into “docile bodies” which have internalized dominant discourses about what is “normal” and

“natural” (Foucault 1979; 1984). Experts in the “human sciences” seek to know and therefore control bodies (Foucault 1973; 1979; 1984). In his work, The Birth of the

Clinic, Foucault describes the medical gaze, where physicians observe and control the body inside and out. Furthermore, with increased concerns about preventative medicine, this gaze extends further and further into the day-to-day health behaviors of individuals

(Foucault 1973). Discipline occurs when people internalize this surveillance and practice it on themselves through ever-advancing disciplinary techniques and technologies.

Resistance is important to the construction of these technologies; as bodies resist being made docile, disciplinary technologies continue to develop to surveil and ultimately control them (Foucault 1979). Far from feeling oppressive, discipline is often conceived as morally responsible self-care. Discipline doesn’t just produce “docile bodies” but builds capacities for self-care and transformation (Heyes 2006; Foucault 1985).

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Feminists have long been concerned with the control and domination of the

body—especially the feminine body (Bordo 1993). Feminist thinkers like Bordo (1993)

and Bartky (1990) have extended Foucault’s ideas about discipline and the production of

“docile bodies” to the production of the feminine body. According to both theorists, body

fat plays an important part in the construction of the ideal feminine body. Bordo (1993)

notes that the fat/thin body takes on a moral meaning about hard work and self-restraint,

wherein thin bodies convey a morally superior character. Bartky (1990) included dieting

and toning exercise as examples of how women’s bodies are disciplined by controlling

every aspect of their bodies. In more recent decades, Heyes (2006) and Throsby (2008)

have explored Weight Watchers and bariatric surgery, respectively, using the framework

laid out by Foucault, Bartky, and Bordo. They argue that while weight loss programs

seek to discipline the body, they also build capacities and provide dieters with a sense of

empowerment. In this way, weight loss programs simultaneously control and empower

women (Heyes 2006).

Bariatric surgery is a form of disciplinary technology (Borello 2010; Throsby

2008). The goals of the surgery are to render the obese body “docile” through a

disciplinary process which constructs thin bodies as morally superior to fat bodies and

encourages patients to engage in lifelong self-surveillance and discipline (Throsby 2008).

Bariatric surgery exemplifies Foucault’s idea that power is not simply restricting but enabling; it doesn’t just punish undisciplined behavior, it rewards disciplined behavior and builds capacities (Thrsoby 2008; Heyes 2006; Foucault 1995). Bariatric patients come to surgery because they feel out of control and paradoxically feel empowered while

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their bodies are under constant surveillance (Ogden, Clementi, and Aylwin 2006;

Throsby 2008).

That dieting, and bariatric surgery specifically, involves disciplinary technique/technology is well established in the literature. This paper seeks to expand this literature by identifying the specific mechanism through which discipline operates in the context of a bariatric clinic. This paper explores the process through which the clinic seeks not only to modify the body through surgery, but to transform the self through a disciplinary process. To do this I am incorporating Goffman’s concept of “the moral career.”

Goffman: Moral Career

The process of obtaining, recovering from, and life after bariatric surgery is much like the moral career of mental patients described by Goffman (1961). Goffman uses the term career to mean “any social strand” in a person’s life course (p. 127). The moral aspects of career come into play when we consider how the career trajectory impacts a person’s sense of self and how a person judges themselves and others. By controlling patients’ time, space, and the props necessary to perform the self, institutions like the mental hospital can construct patients’ selves. Goffman’s theory is particularly useful because it allows for the simultaneous analysis of institutional practices and ideologies as well as internal processes like self-concept and identity.

Embodiment: The Body as Subject

Foucault and Goffman are both important theorists in the sociological study of bodies and embodiment. Foucault’s work on how disciplinary technologies render the body docile is considered seminal in critical bodies studies. However, Foucault has come

46 under some criticism in this field for treating the body as an object—a lump of clay shaped by discourse (Featherstone and Turner 1995; Moore and Casper 2015).

Goffmanian theory is better in this respect. Though Goffman’s works are not explicitly focused on the body, his work on impression management (Crossley 1995; Goffman

1959) and stigma (Goffman 1963) demonstrates the ways in which embodied performance conveys social status and manages stigma, including “abominations of the body” (Goffman 1963:10).

Goffman’s work on the asylum is rarely considered part of the bodies and embodiment canon. I argue, however, that Goffman’s insights about how institutional practices come to bear on the self are useful for understanding the embodied self. Just as the asylum seeks to change the behavior and ultimately the self of the mental patient, the bariatric clinic seeks to modify the behavior and bodies of bariatric patients. While

Goffman’s work begins to push the body into a more subject position, the focus is still on the management of the body in a very mind-over-matter orientation.

Feminist embodiment scholars have challenged this reading of the body as a lump of clay to be molded through interaction and discourse. All selves are embodied; therefore, bodies and embodiment scholars have called for theories which seek to integrate the body in the self (Featherstone and Turner 1995; Moore and Casper 2015).

Budgeon (2003) contends that to truly understand how people experience their embodied identity, we need to see the body as being neither fully subject nor object. Bodies are always encoded with symbols (Bordo 1993), while at the same time we experience and interact with the world as embodied subjects (Moore and Casper 2015). For instance,

Bartky (1990) notes that in addition to resisting the disciplining process of femininity

47 symbolically—as some feminists have—the body itself is a site of resistance. Bodies resist disciplinary regimes by re-growing plucked hair and demanding to be fed through hunger. Any person who has ever tried to lose weight, transition from one gender to another, or faced the changes associated with aging can tell you that despite the best intentions to bring the body in line with social norms, the body often has a will of its own. Through my analysis, I seek to extend Foucauldian and Goffmanian ideas about the body/self to include a more embodied theory of the self.

Findings

These findings describe an ideal-typical analysis of the stages of the bariatric surgery process. Reality is often much messier than the linear stages presented here.

Many patients did not go through this process in a linear fashion. Some had false starts where they started the pre-surgery process and then changed their minds. Others lost their insurance or insurance declined to pay for the procedure. Some patients had multiple bariatric surgeries. Pete had complications with his lap band and opted to undergo Roux- n-Y when they removed the band. Darcy had her gastric sleeve changed to a full Roux-n-

Y. Debbie had the old stomach stapling procedure done in her youth and now sought the more up-to-date Roux-n-Y procedure. Although many of these careers were not perfectly linear, patients still experienced each stage at some point—sometimes repeatedly.

Therefore, they had similar patterns in their experiences to those who went straight through the program without interruption.

Bodies are multiple and so the experience of bodies is shaped by race, class, gender, age, and ability (Hoel 2013). Also, bariatric patients are quick to note that the physical experiences—the way people heal, what they can and cannot eat after, how their

48 personal preferences change—often vary from person to person. However, as Goffman

(1963) notes, people who carry the same stigma—in this case the double fat stigma and

bariatric surgery stigma—have similar learning experiences and changes in the self, i.e.,

similar moral careers (Chaskes 2015). In this ideal-typical analysis, I describe the

common elements of patients’ moral careers.

Pre-Surgery

The Dieting Stage

Like the mental patients described by Goffman (1961), bariatric patient careers

begin before they ever set foot in the bariatric clinic. First, patients must develop what I

refer to as an obese embodied identity17. Obesity is a medicalized term for fatness, defining fat as an illness and giving that medicine the power to define fat and define the proper treatment, i.e., weight loss (Sobal 1995). Likewise, patients with an obese embodied identity must see their fat embodiment as a health problem18 and seek medical

treatment for this problem. The obese embodied identity is one that seeks control over

bodies which they have been trying to discipline for years—often decades. Now they

have turned to the disciplinary power of medicine (Conrad 1992; Foucault 1973) to

finally give them control over their bodies.

Patients offer accounts of how they have come to be fat. For most it has been a

lifelong struggle with their weight starting from childhood. For others their obese

embodied identity developed with age, disability, injury, or illness (Throsby 2007 offers a

17 For a more in-depth discussion of the obese embodied identity, see chapter 1. 18 Whether or not patients defined obesity as an illness varied, but all saw it as a health problem or a potential health problem. Of course, all patients were actively seeking medical treatment for weight loss. 49 detailed account of bariatric patients accounting for their weight). However they come to

be fat, bariatric patients experience their fat bodies as out of control. The vast majority of

patients report a long period of failed attempts at weight loss and yo-yo dieting19. More often than not, patients’ attempts at weight loss represent a lifelong struggle.

All my life. You don't think I haven't tried all, you know, SlimFast and

Weight Watchers and all those, diet pills and whole surgery. The whole

spiel, I've been there and done that… and it's always the same: the dreaded

yo-yo, the roller coaster where you lose it then you gain it back plus. –

Beverly, 48, white, bank loan specialist, pre-surgery patient

Like Beverly, most bariatric patients can rattle off a long list of exercises and weight loss programs, diets, diet pills, and—in Beverly’s case—previous surgeries.

I've had a previous weight loss surgery. I had my stomach stapled like

twenty-eight years ago. I think I was probably like 19 when I had it done.

That was the thing back then. Gastric bypass was just, you know, coming

into light back then and it was still, like, experimental. It was one of those

oh my god, absolute last resort type surgeries. I had the stomach stapling

done and it worked to an extent. I mean I lose like 100 pounds. But it

didn't work for long term and it easily stretched back out. So that just

shows you how long I've been fighting it. – Beverly, 48, white, bank loan

specialist, pre-surgery patient

For Joanne, bariatric surgery was a “no brainer” after failing to lose weight for decades.

19 Yo-yo dieting refers to a pattern of success at weight loss followed by re-gaining weight over and over. 50

It’s a good option. I think if a person is to that point… why would you not

seek medical treatment for a condition that can be treated medically, when

your chances of succeeding on your own without medical treatment is

very slim? –Joanne, 56, white, accountant, 4 years post-surgery

However, not everyone shares Joanne’s viewpoint. Some patients see choosing surgery as a failure after struggling with weight loss for so long.

I have always rejected the surgery in the past when people brought it up,

“I’m not going to do that.” Then doing research in grad school I was like,

“Damn it, this is the only one method for people my size that seems to

actually work.” I thought if I could have done it on my own by now I

would have. It was a big, difficult decision and I was very upset when I

made it, although I’m very excited about it now, although… I don’t like it

now, because it really felt like it was an admission of failure, like I

couldn’t do it myself and I tried and I tried. I lost 6 pounds and gained it

all back and that sort of pattern throughout my life. – Kim, 44, white,

graduate student, pre-surgery patient

This illustrates the sort of double stigma that bariatric patients experience. They are stigmatized for having become fat in the first place. Also, the way they lose weight takes on a moral meaning. Conventional diet and exercise (without surgery) is constructed as morally superior to bariatric surgery. Bariatric surgery is often viewed as extravagant, risky, and “taking the easy way out” (Drew 2011).

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In a way, becoming a bariatric patient is not the start of a career but the

continuation of a much longer career in dieting. With a few exceptions20, bariatric patients have been seeking stigma exit from their spoiled, obese embodied identity for decades. Despite all of these efforts and programs designed to discipline the body—for many psychological, biological, and social reasons—the vast majority of dieters fail to lose weight or maintain significant weight loss (Mann 2015). Patients come to the clinic searching for a way to finally control their bodies and exit their stigmatized obese embodied identities. The clinic reinforces the idea that the bariatric program is about more than just losing weight. For example, the front of the “Patient Education Manual” states in large, bold font “Reclaim Your Life” above an image of a scale with measuring tape draped over it. The message is one of empowerment: bariatric surgery is about taking control of your body and by extension your life.

The Pre-Surgery Process

Once prospective patients decide to undergo bariatric surgery,21 they embark on a lengthy process of meetings, tests, and classes. According to the clinic literature, the pre- surgery process typically takes about 6 months, although the time frame can vary.

Patients report the process taking anywhere from 4 months to over a year. The pre- surgery process is dictated by the clinic’s guidelines and the patient’s health insurance provider, which determine what procedures will and will not be covered. Gatekeepers, such as the surgeons, medical doctors, psychiatrists, and other staff who must approve

20 Amanda gained weight suddenly in later life due to steroid treatments for asthma. She often felt frustrated because she perceived that she lacked information that other patients had from lifelong dieting. 21 For some patients, this decision isn’t final until they have gone through some of the pre-surgery process. 52 patients for surgery, are also important in determining the extent of the pre-surgery process.

Patients describe the pre-surgery process as long and difficult, especially since most are eager to get the surgery as soon as possible. They often feel that they have no control over the process. The clinic dictates what they must do and patients are compelled to follow.

“I felt like a trained animal, jump through this hoop, do this, do this, do

those.” –Larry, 65, white, retired firefighter and small business owner, 1

year post-surgery

The pre-surgery process can be especially frustrating for people with busy work and family lives. The clinic “scheduler” makes the appointments with little feedback from patients. Both Foucault (1995) and Goffman (1961) identified the regulation of time and scheduling of daily activities as a mechanism through which discipline takes place. The schedule of appointments laid out by the bariatric clinic is strictly enforced. If a patient reschedules or misses an appointment, they risk having their surgery date pushed back or getting kicked out of the program altogether. Nichole described one such incident.

I was 2 minutes late for [an appointment]. I had, like, signed in on time.

Then I went to the bathroom, and the person came and said, “We have to

reschedule your appointment. You are late.” – Nichole, 44, white, medical

doctor, pre-surgery patient

Nichole expressed frustration at feeling out of control, especially with her busy schedule as a medical resident.

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The process is frustrating at times, because you feel out of control. Like,

they are controlling the process and you feel desperate. I mean I ended up

feeling, like, desperate, like, part of it is, like, I’m here for one year. It’s a

very busy schedule. I can’t just have the surgery in any given month. I

have to orchestrate my schedule. I have gotten to where I relinquish

myself. It will happen. If it happens in May or it happens in June, it’s not

going to make a difference. It’s a year from now, it will still happen. So

I’ve gotten better at trying to control it less. But the process is challenging.

– Nichole, 44, white, medical doctor, pre-surgery patient

The pre-surgery process is long and at times unpleasant: long weeks of nothing but flavorless Optifast22, organizing work and family obligations around dozens of appointments, invasive medical tests, sleepless nights being observed for a sleep test.

Despite this difficulty, most patients endorse the pre-surgery process as necessary. I group the rationales bariatric patients provide for the pre-surgery process into three categories: 1) preventing surgery risks, 2) socialization, and 3) proving commitment.

Each of these rationales serves an important disciplinary function.

22 Optifast is a trademarked high-protein medical weight loss product. Patients are required to eat nothing but Optifast and a few vegetables in the weeks leading up to surgery to cause them to lose weight. The clinic sells Optifast bars, shakes, and soups. Some patients consider Optifast “not that bad” and continue to use the products during recovery from surgery and beyond. Others have complained that they are flavorless at best and terrible at worst. One patient couldn’t keep her Optifast down so had to be given an alternative liquid diet. I spoke to Victoria during her Optifast period and she complained of feeling tired and weak from such a low calorie diet. 54

First, patients and clinic staff view the pre-surgery procedures as essential to preventing any negative health outcomes from surgery. Many patients believed that the more information the clinic had about their bodies, the better their outcomes would be.

If I’m going to do something that is drastic, I want the medical

professional to have every little tiny piece of knowledge they need to have

on me before I get this done. – Delphine, 55, white, administrative

assistant, pre-surgery patient

To Foucault (1973, 1995) surveillance is key to the discipline of bodies. He refers to “the medical gaze” as a way that medicine practices power by making the patient’s body a matter of knowledge and control—both inside and out (Foucault 1973). Bariatric patients undergo a battery of tests—endoscopy, pulmonary function tests, blood and urine tests, electrocardiogram, etc.—making almost every aspect of their bodies subject to medical knowledge and surveillance.

In addition to subjecting their bodies to the medical gaze, patients undergo psychological screening and sometimes counseling. Patients feel that, in addition to the risks to their physical bodies, the pre-surgery process helps to protect from significant psychological and social risks of bariatric surgery. The gaze of the clinic extends beyond the physical bodies of patients into the realm of controlling their day-to-day thoughts and behaviors (Foucault 1973, 1979). Many patients view their weight gain as stemming from underlying psychological issues like depression, trauma, and disordered eating—

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specifically binge eating. For many, these issues need to be addressed if they are to successfully lose weight after surgery23.

In addition, patients asserted that the pre-surgery process tested whether someone could “handle” the changes that were going to happen in their bodies and their lives.

Patients shared stories of other bariatric patients they knew who needed psychological help after surgery. Perhaps the most striking story is Jane’s who attributes her friend’s behavior after bariatric surgery to a lack of psychological care.

She had surgery. She got thin and she started having affairs on her husband.

Her and I didn’t speak for many years, and we were friends, like, really, really

close. She just turned into this horrible person. It just really affected her in a

negative way. I think it’s because they didn’t know now what they should

have done then. So they… just they didn’t know what to do with… all those

issues. I mean that’s a major difference. You are losing a whole lot of weight.

You are losing a whole person. Basically 360 pounds down to 120, that’s

major difference… now she is okay, but she became an addict. She is in

recovery now. But I mean for 8 years she was just right on the mark, just

dandy. So I do think the way they handle it now is a lot better. – Jane, 44,

white, disabled, pre-surgery patient

23 The notion that fat people are mentally ill is a part of the construction of fat bodies as pathological. For some patients, mental illness, trauma, and addiction are important to their narratives about controlling their fat bodies. It is important to note, however, that not all patients felt that their fat bodies were the result of mental illness, addiction, or trauma. For some, they saw these psychological screenings as important for other patients, but did not consider them necessary for their own treatment. 56

It is a testament to the embodied nature of identity that patients can—often rightly— assume that radical changes to a person’s body, like dramatic weight loss, will radically impact a person’s life. In Jane’s story her friend’s body changed, but her self remained out of control, engaging in drug use and extramarital sexual activity—behaviors that are especially prohibited for women (Bordo 1993; Bartky 1990). While few patients shared a story quite as tragic as Jane’s friend, other patients had similar morality tales of people who lost control after surgery because of a lack of psychological intervention. It's not just the obese body that needs to be brought under control, but also the self.

Patients believe that it requires a certain moral fortitude and perhaps some guidance from the clinic to cope with the changes to the self brought on by rapid, dramatic weight loss. The clinic is not only testing patients’ physical bodies to make sure they are fit for surgery, but also testing their character. The first time Nichole started the pre-surgery process—in a different clinic—the psychologist told her he wanted to be sure she was “resilient.”

The meeting I had with the psychologist, he said, “My whole purpose is

just to decide if you are resilient...” I thought that’s interesting that that’s

what he saw in his role. Like, “I’m going to clear you, if I feel like you are

resilient, because you are going to need to be resilient to go through this

process. So if you aren’t resilient it’s going to become an issue later on.”

So I think the [pre-surgery] process maybe should determine if you are

resilient, rather than just determining it in an hour-long interview and the

process requires some resilience. – Nichole, 44, white, medical doctor,

pre-surgery patient

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Bariatric patients believe the clinic is not just testing patients’ bodies, but also patients’ selves. Getting through the pre-surgery process demonstrates that patients are capable of moving from an out-of-control obese embodied identity to a disciplined bariatric embodied identity.

The second purpose of the pre-surgery process is socialization. Like the asylums and prisons described by Foucault and Goffman, the bariatric clinic seeks to discipline bodies by socializing patients to different behaviors. Clinic staff try to train bariatric patients in how to adopt diet and exercise regimes. The clinic also works to socialize patients in how bariatric bodies function and what these newly reconfigured bodies need.

The most obvious way that patients are socialized is through the required, formal classes.

These classes cover explaining the basics—i.e., the three types of procedures, the clinic’s pre-surgery process, etc. They also have classes on exercise, Optifast, and how to care for bariatric bodies after surgery. In addition to these formal classes, patients are required to meet with nutritionists and often work with the clinic’s medical doctor on a prescribed diet. Clinic practitioners review patients’ food journals and offer them advice on meal planning and substituting items they regularly eat for lower-calorie, higher-protein options. Patients also learn to limit foods that may cause physical discomfort to newly reconfigured bodies after surgery.

Through these diet and exercise practices, patients are learning an important disciplinary lesson—self-surveillance. Through this pre-surgery process, a patient’s eating habits are monitored closely by dieticians and the resident physician. The goal of this monitoring is not to control what a patient eats, but to increase the patients’ capacity to control and surveil their own eating habits. In addition to planning their meals in the

58 day, bariatric patients often count calories in journals or in apps on their phone like

MyFitnessPal. They are encouraged to get a Fitbit or pedometer to monitor their steps throughout the day. Some don’t count calories but kept track of protein and other nutrients.

The clinic teaches patients that this self-surveillance of their food, activity level, and body weight is a lifelong process. This is what patients refer to as “following the program”: adhering to the rules they learned during the pre-surgery process. Patients are given a “Patient Manual,” a large binder full of information about bariatric surgery and how to conduct themselves after surgery. Bariatric patients are quick to note that while popular opinion suggests bariatric surgery is “the easy way out,” bariatric patients must be prepared to monitor their diet and activity levels for the rest of their lives.

Clinic staff reinforce these lessons often throughout the process. Joe found the constant repeating of the same information frustrating.

So, I had 3 or 4 times they explained the procedure, what to expect

afterwards almost every visit. Especially the nutritionist, you understand

how you’re going to eat kind of nothing for the first week… so they were

really good about explaining everything. But I liked I said, sometimes it’s

even overkill. But I am sure in their line of work they want to be sure…

then I’m sure they are going to for insurance purposes, they want to cover

their butts and make sure that you understand everything. – Joe, 64, white,

retired dairy plant supervisor, 5 months post-surgery

He was especially frustrated with the four hour pre-surgery class during which clinic staff go over information that is presented in the “Patient Manual.” For Jane, this process of

59

repeating information and being quizzed by clinic staff helped her to understand “the information overload” she was processing from the clinic and online sources.

It’s just a whole lot of information overload. They give you all the steps

and you read and you forget everything. They tell you when you go back

you’ve got to read it again, because they constantly asking you. Every

time you got to an appointment, they are going to either ask you, “Do you

remember? Can you chew gum after your surgery?” ... because you can

never chew gum ever again in life. Well, I’m like, well, it blew my mind. I

didn’t know that24. – Jane, 44, white, disabled, pre-surgery patient

While patients complained that the classes and all the appointments were inconvenient and sometimes repetitive, most believed that the process really helped them to be prepared for their recovery and life after surgery. They were being socialized into “the program” and taught the rituals of self-surveillance they must perform to transition from an obese embodied identity to a bariatric embodied identity.

The third function of the pre-surgery process is to test patients’ commitment to

“following the program.” Patients believe that the hassle of the pre-surgery process serves this important disciplinary function. In the literature they provide bariatric patients, the clinic emphasizes the need for patients to be committed to changing their own behaviors. Before they are eligible for surgery, patients must sign a “Surgical

Program Administrative Agreement.” Written within this document are stipulations for

“Active Participation” “in all aspects of [Medical Center’s] Program” (clinic documents).

24 After bariatric surgery, patients are not supposed to chew gum because it could get lodged in their newly reconfigured digestive systems and cause blockages. 60

The Client acknowledges and understands that bariatric surgery is only a

catalyst to weight loss. Success in achieving weight loss after surgery is

dependent on the Client’s continued active participation in and adherence

to the Program, proper nutrition, exercise, and lifestyle changes. The

Client understands that, while the success rate for weight loss after

bariatric surgery is encouraging, [Medical Center] makes no guarantee of

weight loss. – New Patient Packet (clinic documents)

The clinic teaches patients that if they “follow the program” they will be successful in losing weight, and if they do not they will face negative health outcomes and will fail to lose (or will gain back) weight.

Patients take these lessons to heart and interpret the failure to lose weight or weight gain using this personal responsibility discourse.

But if you continue to follow your plan, going into this you were told

repeatedly that you need to follow this plan or you [can] gain the weight

back. You have seen some of the celebrities out there who have done it.

But to take a pouch that they have taken from football size down to the

size of banana and you stretch that back out. You are really doing some

things which you shouldn’t be doing. – Kari, 46, Black, insurance claims

adjuster, 5 months post-surgery

Bariatric patients learn to see “following the program” as a moral imperative.

One of my friends she just, she had a bypass, lost 150 pounds, gained a

bunch of it back… she opened her drawer at work and she has got 6 cans

of Pringles sitting at her desk. She had surgery in August. She hasn’t

61 changed a thing, I mean, in my mind my first thought is, “Yeah, she is

going to gain it back because she is not sticking to the plan.” I’ve also seen

that she has only lost 30 pounds since August. That’s August, September,

October, November, December, January, February, only 9 months out and

she has only lost 30 pounds. Whose fault is that? At that point, you have to

ask when, you know, she has got 6 cans of chips at her desk, those are

choices. She is making choices that are keeping her from being successful,

and that’s what I don’t want to do. I don’t want someone to even sit here

saying this to you is in a way is me judging her. I don’t want people to

judge me that way… I don’t want the people to say, “You went through all

of that and you got chips in your desk? What the hell!” – Rosie, 38, white,

customer service and sales, 6 months post-surgery

Bariatric patients shared a number of morality tales where a coworker, family member, friend, friend of a friend, or celebrity failed to lose weight or gained all their weight back after surgery because they did not faithfully “follow the program.” In Goffmanian terms this is the moral aspect of patients’ bariatric careers, where patients are disciplined into a moral framework to judge themselves and others (Goffman 1961).

Most patients view the test of commitment presented by the pre-surgery process positively. They believe that the pre-surgery process is necessarily difficult because adjusting to life after bariatric surgery and continuing to lose weight require that you to make difficult changes and follow disciplinary regimens.

I think it has to be a little rigorous. Because you have to have that

challenge and they to see if you are going to do that. I think there is a

62 psychological element to it all, besides seeing a psychologist… [Patients

must be able] to complete a process because this is a long process

afterwards. It’s much longer and much more regimented… it prepares that

mindset. For some folks that might be a problem, quite frankly… some

folks just have trouble getting organized in their life. You know, it’s a way

of thinking if they are not good at that or they’ve never had to be good at

it. In my mind it’s going to cut back on their results and their goals

afterwards. – Delphine, 55, white, administrative assistant, 3 months post-

surgery

Going through this process of balancing life, work, and all of the appointments proves that you have the organizational skills necessary to deal with the difficulties of caring for your modified body and the discipline to lose weight. Nichole, a busy physician in the middle of her residency, asserted that the process forces patients to make their health a priority.

Everybody is busy but there is a lot of appointments and a lot of

scheduling and having to prioritize that has actually helped me to say this

is my health. I’m going to prioritize this, whether my job feels like there is

room for it or not… so, the process has been getting that way to kind of

prioritize your health, be on top of your appointments and your health and

the things that you need to doing. Being monitored, I think the process is

useful in that way and the length of it is useful. So you get it’s taking me

this long to be comfortable with my decision and not end up with. So if it

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were a shorter process, I don’t know that I would be as clear. – Nichole,

44, white, medical doctor, pre-surgery patient

The pre-surgery process forces patients to make room in their lives for caring for their health. In this way, it helps them to develop greater capacities for self-care. It also gives them time to really reflect on their decision and get comfortable with the long-term implications of their decision.

There are a number of gatekeepers to whom patients have to prove their commitment throughout the process. Most notable are the requirements of insurance.

Most public and private insurance providers require documented attempts at weight loss before they will approve a patient for surgery. Jane had to provide documentation of her weight loss attempts to get her surgery covered by Medicare.

Let’s see, when I started in September I had boatloads of paperwork. But

you have to prove to the government that you have to document every

time you’ve dieted and lost weight. – Jane, 44, white, disabled, pre-

surgery patient

Typically, patients worked with Dr. Miles who instructed them in their diets and documented their progress for the insurance company.

The bottom line is you need to be able to show that you can control your

diet before your insurance company is going to approve you. [Dr. Miles]

said, “You don’t necessarily need to lose weight, but you need to chart this

because we turn this all in before they’ll approve you.” So I did lose

weight during that run in period and he was pretty easy to work with. He

gives me lots of good suggestions whenever I see him as to where to buy

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things. He’s a big proponent more of, what is it? The, like, primitive diet

or whatever it was. – Dona, 57, white, research associate for hospital

network, 2 years post-surgery

The insurance companies—and Dr. Miles by proxy—are important gatekeepers in

determining who can and cannot obtain bariatric surgery. The notion that preoperative

weight loss will result in successful weight loss after surgery has limited support – a

recent systematic review of clinical research found mixed results on the effectiveness of

pre-operative weight loss (Cassie et al. 2011). Yet this demand that patients prove

themselves worthy by losing weight is a common part of the institutional practices of

bariatric clinics and insurers.

In sum, the pre-surgery process is an extensive series of tests, classes, and

appointments—often taking months to complete. This process is designed to test patients

for physical as well as psychological and social risks that could create complications and

prevent them from successfully losing weight. Furthermore, this process is a socialization

process where patients are taught the proper way to eat, exercise, and surveil their bodies.

Finally, patients and providers both describe the process as a test of “commitment” which

eliminates those who do not have the moral fortitude to lose weight after surgery. The

pre-surgery process is designed to prepare and test not only patients’ bodies, but also

their selves. Patients learn to judge themselves and others according to how well they

follow the health behaviors prescribed by the clinic.

Life After Surgery

After surgery, patients can truly transition from an obese embodied identity to a bariatric embodied identity. Bariatric patients do not necessarily conceive themselves to

65 be thin—although many appear to be quite thin. Rather patients think of themselves as less fat or formerly fat. Patients see themselves as freer from illness, pain, and stigma

(more on this in later chapters). Most importantly the bariatric embodied identity is disciplined—patients are empowered with increased capacities to control their bodies.

The bariatric embodied identity is performed through rituals of surveillance and discipline.

Up until this point, the disciplinary process of the clinic has been discursive, socializing patients into self-surveillance practices and testing their moral fortitude. After surgery, another embodied disciplinary component is added where patients literally experience pain and illness when they consume too much food or certain kinds of foods.

Patients often refer to these symptoms as a “tool.” I refer to these as “bariatric symptoms.” Bariatric symptoms include vomiting, diarrhea, “dumping” (where eating too much fat or sugar causes one to sweat, vomit, and/or have diarrhea), lack of appetite, changes in the way food tastes, and a symptom referred to as “restriction.” Restriction occurs when a patient eats too much too fast, or does not chew thoroughly enough; consequently, they experience pain in their esophagus. Patients often describe the resulting chest pains as food “sitting like a brick.” Bariatric symptoms function as a disciplinary technology by literally punishing the body for eating behaviors. It is often an effective way to inhibit the appetite of bariatric patients, disciplining the body’s natural resistance to non-surgical disciplinary techniques of weight loss (Mann 2015; Bartky

1990)

One common mantra bariatric patients repeat is “bariatric surgery is a tool, not a cure.” For bariatric patients, life after surgery is not just about living with a modified

66

body. They must change their entire life to focus on the rituals of diet and exercise. Jodie articulates how her relationship with food has totally changed. She compares her relationship with food to her husband’s, who does not track and think about food like she does.

Because it’s hard. It is, like, wrapped up in my head I would say, it is hard

and you have to be committed to it. Even though you are committed to it,

you still have to work at it. I mean it’s something you… do every day. I

mean over the last 3 years, some days I’ve gotten to a point I will tell my

husband, “I just wish I could live two days it’s like a normal person.” I’m

like, “I want to go to a restaurant. I want to have that deal where you get

the appetizer and the meal and the dessert.” I’m like, “I just want to be

normal. I just don’t want to think about my protein shake and do this and

do that, and track my food.” He looks at me and he is like, “But do you

want to go back?” I’m like, “No.” I’m like, you know, you don’t want to

[gain weight]. But when your relationship with food is an emotional thing

and he and I discuss a lot. My relationship with food is totally different

than his. – Jodie, 59, white, education assistant, 3 years post-surgery

Jodie conceives of her own relationship with food as “emotional” where her eating is out of control like her emotional state—a common discourse about women’s eating (Bordo

1993). As a result, her eating requires constant monitoring and control. She envies her husband’s easy relationship with food.

I characterize life after surgery in three stages, each with their own implications for the self. First is the recovery stage, where patients are not only healing from surgery,

67 but also learning to live with bariatric embodiment—particularly in terms of their relationship with food. Second is the honeymoon stage, which usually occurs within the first year of surgery—although this timeline can vary. During the second stage, patients experience rapid weight loss—shedding with it their obese embodied identities. This stage is characterized by strong embodied symptoms of bariatric surgery and continued connection to the bariatric clinic. Finally, after a year or more patients enter the struggle stage. Of the patients I spoke to, most reported that they have not gain all of their post- surgery weight back. However, for many this stage is a return to the out-of-control obese embodied identity. Patients’ bariatric symptoms begin to fade away as do their connections to the clinic. As a result, patients often return to struggling with conventional diet and exercise.

The Recovery Stage

After surgery, patients begin their recovery and their transition from the obese embodied identity to the bariatric embodied identity. The recovery stage is a key stage in disciplining the body into a new relationship with food. Because the body is healing after surgery, patients experience the most bariatric symptoms during this early stage. Patients eat to accommodate their newly reconfigured bodies and lose as much weight as possible.

Reintroducing food after surgery involves two processes: a formal process where patients move through a prescribed diet from liquids to solid food and an informal process of experimentation. The formal process typically takes about 6 weeks, although patients moved through this process at different rates depending on how much discomfort they experienced from eating. For the first week patients only consume clear liquids. Then they move to creamy liquids the following week, then pureed foods the next week, then

68 soft foods the following week, and so on until they can start eating solid and harder-to- digest foods.

How patients experience this period is related to how acutely they feel the bariatric symptoms, i.e., how well their body processes food and whether or not they experience hunger or desire to eat. For some patients, being restricted to liquid food is easy because they don’t experience hunger. For Kim, trying to eat the prescribed amount of food was difficult because her stomach was “fickle.”

I don’t think they tell you how tough the eating is afterwards. I know they

are kind of like, oh you need for a quarter cup of this and it is like, wow, I

got 3 bites in. But that’s all that’s going. – Kim, 44, white, graduate

student, 1 month post-surgery

But those who did not experience as many bariatric symptoms—especially lack of appetite—found the process more difficult.

At that point I hadn’t had anything with any taste for almost 2 months.

Then it just seemed like the first 3 months you just really couldn’t eat

anything and every commercial that came on TV was about food. Anytime

you drove anywhere, McDonald’s had signs, Filet-O-Fish sandwiches are

on sale, Quarter Pounders are on sale, just everywhere you were so hungry

and you wanted food so bad. It’s like being on the desert with no food and

that’s the part that I said I would never do it again because that was so, so

hard. – Luke, 61, white, retired machine shop owner, 1 year post-surgery

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The “tools” of bariatric surgery are these bariatric symptoms, and for some patients this disciplinary technology was better at shutting down their body’s natural resistance to losing weight than others.

In addition to the formal process of moving from liquids to solids, patients undertook an experimental process where they tried different foods to figure out which foods worked for them and which didn’t. This means that patients need to figure out which foods are optimally nutritious, don’t upset their stomach or cause dumping syndrome, and taste good enough to eat. Through experimentation, some people discovered they can handle certain foods earlier than the formal process dictates. Darcy found that her return to solid foods was quicker after her second bariatric surgery, when she had her gastric sleeve modified into the full Roux-n-Y procedure.

At least the first time I remember and then I started eating solid foods too

soon and I got sick and it was bad. The second time around I did go back

to solid food quicker but it was like I felt like it was easier because maybe

I had already had the surgery. I didn’t have any problems at that time

period but a little sooner and the dietician was fine with me going back

sooner as long as I was tolerating it. – Darcy, 31, white, home health care

worker, 5 years post-gastric sleeve and 2 years post-Roux-n-Y

Others found that their bodies’ responses to food made them move more slowly through the process than the formal process required.

I followed the diet pretty close. I was excited to get off liquids to soft, but

moving from soft to the later normal foods, I probably went slower than

was allowed. But it just, soft foods were easier and some foods just upset.

70

If it didn’t sit well like chicken, chicken it took me 4 months to be able to

eat. If it didn’t sit well, I didn’t eat it. There were the foods that I felt I

could eat and I ate those. – Joanne, 56, white, accountant, 4 years post-

surgery

Most patients have certain foods they cannot eat during this time, most commonly meat, but patients reported sensitivity to bread, certain sea foods, eggs, and even water.

Patients have a certain amount of freedom in the diet to figure out what they like and what foods work for them, but they are still expected to keep this experimentation within the rules laid out by the bariatric program. Many patients advocate sticking closely to the prescribed steps. Jodie describes being afraid to stray from the prescribed early diet.

I will say that, I mean I’ve not had much stomach and back pain. But I was

very compliant, because as I tell people. I’m like, it wasn’t because of my,

like, great fortune tutoring. I was terrified. People would say like, “How

did you get do it?” I’m like, “Well, I was afraid.” “But, like, you never

cheat?” I am like, “No.” Oh my gosh, I would have been terrified to eat

something a day before they told me I was allowed to. [sic] I was afraid I

would get sick. Yeah, I was afraid I would get sick or I just didn’t want to

screw it up. I had done too much work and I still to this day, I don’t want

to screw it up. I mean it was hard. – Jodie, 51, white, education assistant,

3 years post-surgery

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By “screw it up,” Jodie means she was afraid that deviating from the prescribed diet would cause her to gain weight. The implication is that failing to “follow the program” will result in sickness, weight gain, and ultimately moral failure.

In addition to learning what foods will and won’t make them sick, bariatric patients are also learning how to integrate a bariatric diet into their day-to-day life.

Bariatric patients must change the rituals around the planning, preparing, and consuming of food. The cultural meaning of food and eating are central to our sense of self and embodied experiences (Lupton 1996). One of the keys to performing the bariatric identity is about adopting new rituals around food. These food rituals require practice and experimentation. Joanne describes needing additional time off work to manage her new diet.

It was, I think my recovery was more about learning how to eat right and

the timing. You eat such small amounts and you have to eat so often that I

was off work I think 5 weeks. I really needed that time to kind of

reorganize my personal eating to come back to work… you’re eating more

food frequently and smaller amounts. It might be a couple spoonful of

cottage cheese and then an hour later, one meatball with a little bit of

sauce or a hardboiled egg. You’re so concentrating on learning what you

can’t eat and you can eat. What sits well and what doesn’t sit well. You

know, getting up and moving around. Getting your water in between

eating and not eating at the same time you’re drinking water. You just in

such, you have to set up such a regimen and when you’re going to get your

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vitamins in in between all that. It’s a full-time job for a while at the

beginning. – Joanne, 56, white, accountant, 4 years post-surgery

There are a number of factors involved in developing disciplined eating rituals for bariatric patients. There is the issue of the formal rules of “following the program” which includes closely monitoring and planning food consumption, following formal rules of what you can and cannot eat, etc. Patients are even taught rituals around how they must take medications25 and consume liquids. Liquid should not be consumed less than an hour before and after eating and yet patients are required to consume the standard 8 oz. of water each day. In addition to the disciplinary tenets of “following the program,” patients are learning what foods are intolerable to their systems and what eating practices—i.e., eating too much or too fast—will produce bariatric symptoms. All of this requires a great deal of time and energy to implement these rituals into a person’s day to day life.

Integrating their food rituals into patients’ personal lives can be challenging. Food is often a key part of important social and cultural rituals as well as a key part of family life (Lupton 1996). Jodi had a busy social and family life that often involved sharing meals together. She adjusted by bringing her own food with her.

But, like, we go out like family. We go out on Sundays, we’ve got kids

after church for lunch or something. I would just take my stuff with me. I

would just mix my soup, I bought a little thermos. I would just take my

soup and just whatever I was doing, I would just drink it. I did that after

surgery too so that I could be with people who will be having dinner, like

family dinner. So I knew we had friends, but that way I could be with

25 More on this in chapter 5 73

them and have something and do that with them. So I wasn’t feeling like I

was missing out on my complete social life. – Jodie, 59, white, education

assistant, 3 years post-surgery

Others were not quite so successful at integrating their eating rituals into family gatherings. For instance, Kate’s family said they felt guilty eating in front of her so they would take their food into another room, leaving Kate to eat alone during her recovery.

For most patients, their loved ones learned to adapt their food-based rituals like family meals, gatherings, and celebrations to accommodate patients’ dietary needs. Margret’s

(36, white, homemaker, 1 year post-surgery) family, for instance, began focusing family gatherings around outdoor activities for the kids instead of large group meals.

Recovery is a crucial period for performing the bariatric embodied self. During the pre-surgery process, patients are practicing the rituals of self-surveillance required to

“follow the program.” After surgery, the body has been modified to include embodied disciplinary mechanisms—bariatric symptoms. Now patients must follow the program guidelines to prevent sickness and injury to their newly reconfigured bodies. They must learn to adapt their fickle bodies and demanding food-based rituals into their lives and this takes time, practice, and negotiation with others.

The Honeymoon Stage

There are two distinct periods described by patients after they have recovered from surgery. Maggie had bariatric surgery over a decade ago. She described two post- surgery periods—the “honeymoon stage” and the “struggling stage.”

You are going to go through what we call the honeymoon stage where

everything is just like I can’t quit losing weight and it’s just peeling right

74

off you. But after that year is up, a year to 2 years depending on your size

when you start, it’s over… then I got to be stand still (in terms of losing

weight) for a long time and then you can struggle just like everybody else

and that’s where I’m at. I’m at the struggling stage. – Maggie, 49, white,

small business owner, 11 years post-surgery

What Maggie terms “the honeymoon stage” is a period of time when patients are losing

weight quickly. Patients report this period to last anywhere from 6 months to 3 years, but

it usually concludes within the first year. The most common complaint/brag during this

time is that it’s difficult and expensive to purchase clothing for a rapidly changing body.

When you are in the honeymoon stages, those are fun stages where it’s

just melting off and you can’t even buy clothes because it’s the opposite.

Where it’s like when I was gaining weight it was like I can’t buy clothes

because as soon as I buy something I outgrew it. And it’s like when you

are in the honeymoon stage you go to the store and it’s like [sic] you don’t

even know size you are. [sic] You go from a 24 to a 18 and you don’t even

know it yet. Then you put on eighteens and you think I just got this and

now the sixteens are too big. So, it’s an amazing stage. – Maggie, 59,

white, small business owner, 11 years post-surgery

The experience of rapidly changing sizes and fitting into smaller and smaller sizes is a thrilling experience for most bariatric patients. The size of the clothes is as important as weight as a marker for bariatric progress. Bariatric patients find that their new performances of self require a completely different costume. A lot of this early weight loss can be attributed to strong bariatric symptoms. While most people’s symptoms have

75 lessened from the recovery stage, people in this early stage still experience many bariatric

symptoms such as change of appetite, dumping syndrome, and restriction

For most bariatric patients, their rapidly changing bodies come with rapidly

changing selves. Most significantly, many reported a stronger sense of self-confidence

which changed the way they performed their selves for others.

I have a lot more confidence in myself… I've actually lost some friends

because I used to just, you know, sit there and agree with everybody and,

like, I just felt like this shell of a person because I was depressed. I didn't

do anything. I didn't go anywhere. And now I carry myself totally

different… I just carry myself totally different. I have a lot more

confidence in myself. I'm not afraid of what other people think of me at

all. – Margret, 36, white, unemployed homemaker, 1 year post-surgery

Bariatric patients who have lost significant weight often feel freed from the shame they

carried with their visibly fat bodies. Having a body that is visibly “normal” allowed

patients to feel more confident in social interaction with others. With Margret’s growing

confidence, she was able to get away from toxic relationships with jealous friends who

she felt took advantage of her lack of self-confidence in the past.

Some bariatric patients noted that it wasn’t just how they felt about themselves that had changed, but also the ways in which other people interacted with them. Pauline noted that salespeople and strangers are much friendlier now that she is thinner.

I'm not ignored as much. Like I said, we go to car dealers for something to

do… and when I weighed more, I think that I was blown off. 'Cause I don't

go with my husband, I go with [my daughter]. And now they take me

76 more seriously. You know, you walk into a dealership and it's like, "How

can I help you?" You know. It's different. I'm not no happy person but I

try to smile more often. But it is different. People talk to me… I got into a

conversation with a woman about my age—no, she was maybe a little

younger—but we just chatted and this would have never happened before.

It was kind of nice. – Pauline, 59, white, full time caretaker of daughter

(former nurse), 1 year post-surgery

For anyone with a stigmatized identity, managing that identity in public is a challenge

(Goffman 1963). This is especially true for people who carry a visible, embodied stigma like fat people. The obese embodied identity is an identity that is always discredited

(Saguy and Ward 2011). For patients who have lost a large amount of weight during the honeymoon stage, their double stigmatized status as a bariatric patient and a formerly fat person can be considered discreditable. In fact, patients are often very careful in how they disclose their bariatric embodied identity to others. For many, they get to move through the world as a “normal person,” which creates greater ease in social interaction (Goffman

1963).

Identities are the product of interaction with others (Crossley 1995; Goffman

1963). The self-confidence bariatric patients experience while losing weight stems from the change in status created by transitioning from a visibly fat body to a body that appears to be “normal.” Friends, family, and co-workers praise bariatric patients for their diminishing bodies and disciplined eating and exercise rituals. Strangers treat patients with more respect and courtesy. Even physical space is easier to navigate when your body literally “fits in.” All of these things reinforce bariatric patients’ self-confidence.

77 Many patients within this first year after surgery were keenly aware that the honeymoon stage would not last forever. In fact, the clinic teaches patients to expect an end to the early, rapid weight loss. Still, the possibility of weight gain after surgery felt remote to many people during this stage.

I'm pleased with my weight loss. I'm still heavy but I see my clothes size

going down. I have more energy… I mean I know you can gain weight but

being this far out with the taste changes and everything, I seriously doubt

that I will re-gain. Whether I'll lose everything I want to I don't know. But

I expected that to begin with. – Pauline, 59, white, full time caretaker of

daughter (former nurse), 1 year post-surgery

Because of the strong embodied bariatric symptoms and the rapid weight loss, many patients at this stage feel confident that they will not gain the weight back.

Still others are concerned about taking advantage of the honeymoon stage and losing as much weight as possible. Kelly was even willing to do so at the expense of her getting the nutrients she needed.

180 pounds, if you think about it, it’s a not-so-small person and that’s how

much I lost and to lose that much is huge for me and when I step on the

scale and it’s all and you have 125 more pounds to go, I’m this is amazing.

I’m probably deficient in every single one of my vitamin categories and

probably protein too. But I’m working on that. I mean that’s something I

kind of honestly work on. That’s something that I will eventually get right.

But if you don’t lose the weight at first then you will never because there

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is a window of the time when the surgery actually helps you and then after

that it doesn’t help it. – Kelly, 29, white, unemployed and disabled

When I asked Kelly26 what her doctors thought of her pushing for weight loss at the expense of nutrients, she said that her doctors “have been on [her] about nutrition from day one.” But to Kelly, getting these results was more important than getting the appropriate amount of protein and vitamins. It’s important to note that most of the patients I spoke to were not nearly as cavalier about the importance of proper nutrition.

However, many felt that they needed to lose as much weight as possible before the first year was up and the “struggling stage” began.

The Struggling Stage

The “struggling stage” begins at the end of the “honeymoon stage,” usually about a year from surgery. This is when patients are at the greatest risk of gaining weight. Lucy plateaued about a year and a half after surgery and began to notice weight gain around 3 years after surgery.

It came off really fast, probably 1 ½ years, I had lost most of that. I

thought it was not going to be a problem and everything was going good

and this is the best thing I’ve ever done. But then 5 pounds here and 5

pounds there, and the next thing you know, you are 20 pounds overweight.

– Lucy, 66, white, retired medical technician, 9 years post-surgery

Most patients who were a year or more from their surgery date reported gaining some weight back. According to clinic practitioners and literature, it is normal for

26 Kelly even ended up in the emergency room after passing out from low blood sugar and hitting her head. 79 patients to gain 10–15 pounds at this stage. None of the patients I spoke to reported gaining all of their weight back. However, some had gained a little weight back (between

10–25 pounds) and others had gained a substantial amount of weight back (between 40–

100 pounds)(Christou, Look, and MacLean 2006; Karmali et al. 2013). Bariatric patients find themselves part of the remission society described by Frank (2013), where bariatric embodied identities are at risk of reverting back to the out-of-control obese embodied identities.

Many patients can become disillusioned when they gain weight back or don’t lose as much as they would like. Pete is critical of other patients who blame the surgery for their own weight gain, rather than looking to their own expectations.

I think what happens with a lot of bariatric patients is that they get further

out. I mean people start to gain weight, there is no question about that… a

lot of people can become very disillusioned… I think they get

disillusioned by thinking and the thing I hear a lot is, “I failed at it” or

something. “I was a failure.” Never such a thing as a success or a failure at

this. It’s sort of like it’s a surgery… I mean we always said we all know

why you gain weight, eating more, not being active. It is pretty complex

but to blame the surgery, I just think it is a disillusion… I think what

happens is and unfortunately the surgeon used to say, “I think you are

going to be this weight.” People set that in their mind like, “Okay, this is

success.” This is sort of like hitting the bell thing up. So, if I get to like

128 pounds or whatever it is, I’m going to be a success… of course as

time goes on it becomes harder and people naturally gain weight, that

80 [goal weight] gets further away. I think that causes a lot of disillusion. –

Pete, 61, white, data architect, 7 years post-lap band and 2 years post-

Roux-n-Y

The ASMBS defines successful weight loss after bariatric surgery as a patient losing half

of their “excess body weight” and maintaining that weight loss. As Boero (2012)

discussed in her study of bariatric patients, often this criteria for success rarely matches patients’ goals and expectations. Patients often want to lose as much weight as possible— getting as close as they possibly can to the thin ideal. Pete and other patients in the struggle stage sometimes felt critical of other patients for not harboring realistic expectations and focusing on their goal weight over health outcomes.

One of the major reasons why weight gain is so common among patients at this stage is that the embodied component of bariatric discipline—the bariatric symptoms that result from their reconfigured systems—starts to wear off. Maggie felt like she was “back to square one,” meaning she didn’t have any more bariatric symptoms from surgery and was back to the kinds of dieting behaviors she engaged in before surgery.

But being this far out in surgery I feel like I’m starting all over, like I

never had this surgery and now it’s just basic, meaning you have to count

your calories, you have to go to the meetings then you have to exercise

and it’s all that stuff they tell you to do before the surgery and you can’t

do it. It’s just people with weight problems just can’t do it or they can but

they have to go to meetings and you really got to be into it. It’s not a

magic like I’m going to have this surgery and this is going to cure me for

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the rest of my life. It’s not. – Maggie, 49, white, small business owner, 11

years post-surgery

Maggie feels as though she never had the surgery in the first place. She is essentially back to her previous out-of-control obese embodied identity—struggling with the same yo-yo dieting practices she engaged in before coming to the clinic.

Patients often blame themselves for their weight gain. They even blame themselves when they feel less restriction—believing that their increased eating had

“stretched their pouch”—when their stomach pouch stretches from holding too much food. Luke began to feel himself losing restriction about a year from this original surgery.

But now with the surgery I think I have stretched my pouch because I can

eat more. I go to the support groups and people still are only eating a

couple ounces of food at a time. I eat a whole lot more than a couple of

ounces and I’m thinking I must have really screwed myself up eating too

much and I’m bothered right now because I haven’t lost any weight. The

last time I went to my 1 year visit I’d lost weight but nothing like I wanted

to lose. In the beginning you lose a lot, big leaps at a time. Well, now if I

lose a couple of pounds a month I’m lucky. Well, that doesn’t give you the

excitement to keep going and Doctor D says that’s normal and once you

hit a certain spot you are pretty much going to stay there. – Luke, 61,

white, retired machine shop owner, 1 year post-surgery

Even though the surgeon told Luke that this slowdown of weight loss after a year was normal, Luke still feels responsible for eating more and feeling less restriction.

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Of course, some patients do not gain back the weight. Diana is three years out from her surgery and quite successful in terms of weight loss. She had met her goals in terms of weight loss and was maintaining and even losing a little—even though she doesn’t really check her weight on a regular basis.

I've never been a scale person. That jump on the scale, check my weight.

Only if the doctor needs to. I have a scale. I don't get on it. I mean I don't

need to. When I come—I used to come back for my check-ups. First thing

you do is you get on the scale and it's like, "You're down three pounds." I

don't even know what I did to get 3 pounds off. How did it happen? And

then it was like, "I don't know what you're doing, but keep it up." Ok, what

did I do? – Diana, 57, Black, hospital custodian, 3 years post-surgery

Part of Diana’s success can be attributed to her work. Even though I met her after fasting and getting blood drawn, she was still bubbly and energetic. Her descriptions of her life made her sound like a woman constantly on the move. Not only does Diana not track her weight on the scale, she also doesn’t keep close track of her food intake. What Diana and other successful bariatric patients do is practice what might be considered mindful eating—paying attention to fullness cues and how foods make them feel (Mann 2015).

People know that's been around me know: when I say I'm done, I'm done.

Don't entice me with more food 'cause it's not gonna happen. – Diana, 57,

Black, hospital custodian, 3 years post-surgery

Diana ate pretty much whatever she wanted in moderation and avoided sweets. She is aided by the fact that she still feels her restriction and pays close attention to it. Now, whether she is lucky and has kept her restriction after her body healed or her attention to

83 the restriction prevented her stomach from stretching is unclear. What does seem clear is that those patients who still experience bariatric symptoms report having less trouble preventing weight gain after surgery.

In addition to losing the physical symptoms of bariatric surgery, patients begin to lose touch with the clinic the further from their surgery they are.

Well unfortunately for me I guess other than Erma and May and Pete and

Maggie… there aren’t that many that are further out that have still come to

the support groups and stuff. It seems like after about 3 or 4 years they

kind of fade away, either because they are doing well on their own or they

are not and they are too ashamed to come back. I know folks on both ends

of that spectrum. – Kate, 41, white, Medicare reimbursement specialist, 5

years post-surgery

Unlike the asylum of which Goffman wrote, the clinic is not a total institution. Patients live most of their lives outside of the clinic and as they begin to spend less and less time there the influences of the outside world start to overtake the socialization of the clinic.

Slowly you forget where you were at and you kind of forget the program

and you get away from people and now you are just around normal people

that didn’t have [bariatric surgery] – Maggie, 49, white, small business

owner, 11 years post-surgery

Many patients feel that it’s no longer necessary to come to the clinic after a certain period. When I asked Gabby how long it had been since her last appointment, she said it had been quite a while.

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So I just went and got my blood work done. I got a call from [clinic

dietician saying,] “All your blood work looked good. Your protein levels

are a little low. Work on getting protein in.” And that was the end of it.

And then in my head I'm thinking, well, why do I need to spend the money

for a copay to go in and all they ask me is, “Are you going to support

groups meetings? Are you eating right and are you exercising?” And when

if I just get my blood work done do I really need to go see the doctor?...

So, it's been a year and a half since I've actually had an appointment

besides just getting my yearly blood work done and them calling me and

saying, “Hey, it's bad” or “It's good.” – Gabby, 50, white, retail worker, 1

year post-surgery

Many patients years after the surgery begin to feel that the inconvenience and cost of the extra appointments with the clinic do not outweigh the benefits and stop coming in for formal appointments.

In addition to formal yearly checkups and blood work, the clinic provides two support groups—one of which is focused on helping post-surgery patients “stay on track.” However, many patients in the struggling stage reported feeling frustrated with the groups—especially since the groups seem to focus mostly on “newbies” that are still in the honeymoon stage. During one meeting this tension came to a head.

But I am not real thrilled with the support groups. I told you about how

they, once you get out so far out, you are just kind of forgotten. I think you

are left dangling. If I hear one more time, “I’m so glad there are older

people in there to help the new ones that have had it done.” I don’t want to

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hear that. I am not there to help some new person… I’m there for myself.

– Lucy, 66, white, retired medical technician, 9 years post-surgery

For people in the struggling stage it can be frustrating being expected to mentor newer bariatric patients, especially when they came to the support group seeking help for their own struggles.

I said to my friend, “I wish somebody”—and I feel this strongly—“I wish

somebody could just tell me something I don’t know.” I know everything.

I do! You can’t tell me anything that I don’t know about weight loss. I’ve

been to dieticians, I’ve had surgery, I’ve been to Weight Watchers and the

gamer. You can’t tell me anything, it’s just tell me how to get back to

square 1. I can’t have the surgery again so what do you do for patients that

have been out like 10 years? And the lady avoided the questions because

she didn’t have an answer for it… I believe there is no help for people 10

years out… don’t tell me exercise or see a shrink or, tell me something.

It’s like then they can’t. They can tell all the newbie stuff and then she

said in the meeting when I first started and it kind of irritated me was,

“Good you’ve been out that long. I’m sure you have a lot of advice for

them”… I said, “I don’t want to give advice what they haven’t done. I

want someone to give me advice or my friend.” So, who gives us advice?

– Maggie, 49, white, small business owner, 11 years post-surgery

Maggie and others in the struggling stage feel frustrated that the only advice the clinic can offer is to count calories and attend support groups. Some patients have met with counselors and with dieticians to discuss meal plans. For the most part, bariatric patients

86 have been dieting their whole lives and so none of the advice clinic staff offers is new information. Essentially patients are at the struggling stage—back to battling with their out-of-control obese embodied identities.

Conclusion

In this chapter, I argue that the process of obtaining, recovering from, and living after bariatric surgery represents both a disciplinary process and a moral career. This moral career consists of two periods: life before and life after surgery. I’ve broken life before surgery down further into two stages. First, the dieting stage, where future patients struggle with their obese embodied self. They see their body fat as a problem and try to solve it through a number of diet and exercise programs—often losing weight only to gain it back again repeatedly. Their often lifelong struggle with weight cycling makes them feel as though their body is out of control. Seeking this control, they come to the bariatric clinic. The second stage is the pre-surgery process. Once patients enter the program, they must undergo a rigorous process of testing, classes, and appointments with specialists. This process can take 6 months to over a year. The pre-surgery process serves three functions: 1) it tests patients’ physical and psychological health, 2) it provides patients with important information and socialization, and 3) it tests patients’ moral fortitude—are they able to stick to the self-surveillance of “following the program” for the rest of their lives? Once the process is complete and patients have proven themselves good candidates for surgery—physically and morally—patients are approved for surgery.

Bariatric patients experience life after surgery in three distinct stages. During these stages, patients transition from the out-of-control obese embodied self into the disciplined bariatric embodied self. The first stage, recovery, occurs in the months after

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surgery. During this time patients are following guidelines from the clinic to gradually move from a liquid diet to eating solid food again. This is also a time when patients are experimenting with which foods taste good, provide nutrients, and do not cause bariatric symptoms. Patients must change the rituals associated with the preparation and consumption of food in order to perform their new bariatric embodied self. Second, patients enter “the honeymoon stage.” This stage is characterized by rapid weight loss and strong bariatric symptoms. Patients experience changes both inside and out as they buy new clothes, physically fit in to more spaces, and experience greater confidence.

Their new bariatric embodied selves appear more “normal” and they are treated accordingly by others. Finally, most patients enter “the struggle stage.” Patients reported experiencing weight gain as early as one year after surgery and sometimes as late as 3 years. While two patients in my sample were more than three years from surgery and still maintaining their weight loss, for the vast majority they experienced at least some weight gain. Partially, this is because patients begin to lose bariatric symptoms and their restrictive function. The other reason is that patients often lose touch with the surveillance function of the clinic.

Throughout the moral career of the bariatric patient, bariatric patients participate in two interrelated disciplinary processes. First is a discursive process which consists of the sorts of control and socialization techniques similar to those outlined by Foucault

(1979) and Goffman (1961). Patients are put on a tight schedule and penalized for deviating from this schedule through delaying surgery or removing patients from the program altogether. Patients’ behavior and bodies are subject to intensive surveillance.

Patients are educated and tested throughout the pre-surgery process through formal

88 classes and demands that they demonstrate that they are capable of the work required to lose weight and maintain that weight loss after surgery. While patients are building capacities for self-discipline and transformation through this process, they are also reinforcing a moral framework to judge themselves and others. Patients learn to view the practices of self-surveillance or “following the program” as a moral imperative. Patients view those who fail to lose weight or who re-gain weight as moral failures and blame themselves for failure to reach their goal weight. This moral ideology stems from moral ideologies in the larger culture about fat/thin bodies where fat bodies are viewed as undisciplined and out of control while thin bodies are a sign of moral fortitude and self- denial (Bordo 1993).

The second disciplinary process is an embodied process. Bodies resist weight loss through a number of psychological and biological mechanisms—this is why almost all dieters fail in their efforts (Mann 2015; Bartky 1990) . Bariatric surgery seeks to subvert this resistance by modifying the body so that it can hold less food. Bariatric symptoms such as loss of appetite, change in the way food tastes, vomiting, diarrhea, “dumping,” and feelings of pain in the chest or “restriction” are important embodied disciplinary tools; in fact, many patients even refer to the surgery as their “tool.” This process starts after surgery and reinforces the moral disciplinary techniques introduced at the very beginning of the process. For most patients, these symptoms are strongest in the beginning and start to wear off as patients move further from their surgery date.

Even these embodied, physiological symptoms work in tandem with the discursive discipline of the pre-surgery program. This modified digestive system and the associated symptoms counteract the body’s feelings of hunger and punish patients for

89 giving in and eating too much, too fast, or certain foods. “Not following the program” can literally result in extremely unpleasant bariatric symptoms. The further a patient is from surgery, the more the body heals and adjusts and the less patients feel symptoms. Patients who are years from their surgery date may feel almost no bariatric symptoms. Patients often gain weight as a result. This comes with a great deal of self-blame. Patients may blame themselves for failing to follow the program as closely as possible before/after their “tool” begins to fade. Patients often view the loss of these symptoms as their fault for “stretching out their pouch” or “eating around their restriction.” The embodied experience of weight gain and weight loss represents a moral failure and success respectively.

Connecting the discursive and identity processes with the lived experiences of the body helps us to better understand how someone transitions from an obese embodied identity to a bariatric embodied identity. Bodies are not purely subjects, but they are not totally objects either (Budgeon 2003). Bodies are always encoded with symbols (Bordo

1993), while at the same time we experience and interact with the world as embodied subjects. In order to truly understand how people experience their embodied identities we need to see bodies not as objects but as processes (Budgeon 2003). The bariatric embodied identity is produced through the struggle to leave behind an obese embodied identity. It is constructed through acts of self-surveillance and discipline, but also through embodied symptoms like restriction, dumping, or lack of appetite.

Where the obese embodied identity is out of control, a bariatric embodied identity is performed through disciplined rituals of exercise, preparing and consuming food, and surveilling the body. Any weight loss program will require these practices, but the vast

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majority of dieters who engage in these practices will fail (Mann 2015). When we think of the body as a process rather than an object, it opens the possibility that the body itself can be a site of resistance on a corporal level (Bartky 1990). The body resists traditional weight loss strategies because the body resists extreme changes in weight through psychological and physiological mechanisms (Mann 2015; Bartky 1990). This exemplifies Foucault’s (1979) ideas about the nature of discipline and resistance; resistance will always occur and disciplinary technologies will continue to develop to meet this resistance. Bariatric medicine continues to develop both discursive and surgical techniques to more effectively combat bodies’ resistance to weight loss. For most patients the body continues to resist these efforts after surgery. As time marches on the body heals, stretches, craves, and hungers, seeking to return to equilibrium. Bariatric patients struggle against these efforts with waning connections to the discursive power of the clinic. While the bariatric embodied identity is developed to leave the obese embodied identity behind, bariatric embodied identities are forever threatened by the possibility of remission back into an obese embodied identity.

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CHAPTER IV

FREE BUT REGIMENTED, SICK BUT HEALTHY

BARIATRIC PATIETNS’ HEALTH AND ILLNESS EXPERENCES

For decades, obesity has been debated by public health officials, academics, scientists, physicians, politicians, media talking heads, and activists (Saguy and Riley

2005). It is often difficult to hear the voices of the people whose bodies are so contested above the din of these moral and medical discourses. In this chapter, I discuss themes that emerged in bariatric patients’ descriptions of their own embodied experiences of health and illness. What does it feel like to live in a heavy body? What does it feel like to live with a modified digestive system?

Bariatric patients discuss obesity as an illness experience. They describe a longing to be free—free to move through the world without the painful burden of their heavy bodies and free from the medications they take for chronic illness. After surgery, they describe feeling healthy—being freer to move and taking fewer medications. However, they must contend with the symptoms of their reconfigured digestive system, many of which would be intolerable to non-reconfigured bodies and other post-surgery patients.

Patients normalize and reframe these symptoms in a number of ways which allow them to construct their embodied identity as healthy (or at least healthier than before surgery).

Sociologists examining the illness experience have long maintained that these experiences shape and are shaped by the social construction of illness. Discourses about health—especially with regard to fat—have taken on a distinctly moral character (Metzl and Kirkland 2010). In this chapter, I will examine how the moral discourses about

92 fatness, fitness, health, and chronic illness impact how patients account for their own experiences of health and illness.

The Social Construction of Illness and Obesity

Medical sociologists have long asserted that illness is socially constructed. This is not to say that there are not real material, biological, and physiological aspects of disease; however, the diagnosis, treatment, and classification of disease are all social processes.

Furthermore, the socially constructed meaning of illness has impacts on sufferers beyond the physiological and biological effects of disease (Conrad and Barker 2010). For instance, disability scholars have long made a distinction between physical impairment and disability. While physical impairments are often biological or genetic (though they are also socially produced through things like accidents, pollutions, etc.), disability itself is socially produced through barriers in the built environment, capitalist cultural demands for increasing the pace of productivity, and other social factors (Conrad and Barker 2010;

Wendell 2015).

Discourses of health and medicine wield enormous power to define reality.

Sociologists refer to this definitional power of medicine as medicalization.

Demedicalization is possible—for instance, homosexuality was once diagnosed and treated as a mental disorder until lesbian and gay activists successfully removed the diagnosis from the DSM and the treatment of homosexuality from mainstream psychiatric practice. However, in most areas medicalization is expanded ever deeper, defining more conditions as illnesses which should be treated medically (Conrad 1992).

In fact, medicine has become a major institution of social control (Conrad 1992; Metzl and Kirkland 2010; Zola 1972). Medicalization is a double-edged sword. On the one

93 hand, defining a condition as a disease entity can destigmatize the phenomenon. On the

other hand, medicalization individualizes and depoliticizes a problem, which can

eliminate some of the destigmatizing effects (Boero 2012; Conrad 1992).

The study of stigmatized illness is an important vein in the social constructionist approach to health and illness. Based in the work of Erving Goffman (1963), sociologists of medicine have concluded that the stigma carried by certain illnesses has real implications for the experiences of sufferers as well as for institutional and political policy (Conrad and Barker 2010). In fact, Hatzenbuehler, Phelan, and Link (2013) argue that stigma is a fundamental cause of health and illness—impacting stigmatized populations’ ability to access and utilize resources necessary for health and wellbeing.

In addition to specific medical conditions carrying a social stigma, health itself

takes on a moral meaning (Crawford 1980; Metzl and Kirkland 2010). In our culture, we

believe that health is an individual responsibility. Much of the public health rhetoric

focuses on promoting individual behavior—despite mounting evidence that this focus is

not effective in improving population health inequalities (Baum and Fisher 2014). This

focus on behavior not only obscures larger social structural issues—i.e., unequal access

to health and wellbeing promoting resources—but also creates a sense of stigma against

those who are unhealthy. Crawford (1980, 1994) argues that our emphasis on health as a

moral good and an individual responsibility has created “unhealthy others” —people who are stigmatized because their ill health is perceived as their own fault. Furthermore,

Adele Clark (et al. 2010) argues that we have entered an era of biomedicalization where increasing developments in biomedical technology have expanded the ways in which

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medicine can treat and modify the body. With this expansion of technological interventions comes a moral obligation to optimize health using biotechnology.

Obesity is a classic example of a bodily condition that has become stigmatized and medicalized. Fat studies scholars point out that fat bodies used to be a sign of high social status during a time when only the most privileged person could afford the food and leisure time to grow fat, while most others worked manual labor, struggled with food shortages, and faced increased risk of infectious disease. In the age of modernity in the

20th century, thinness became a marker of privilege since only those with means could afford the free time and resources to cultivate a thin figure (Farrell 2011; Fraser 2009;

Stearns 1997). With the shift from fat as a symbol of high status to a symbol of low status came a moral shift in the view of fatness. Fat bodies have come to embody laziness, greed, gluttony, unhealthiness, unattractiveness, and a host of other unflattering stereotypes.

Towards the beginning of the 21st century, a new discourse about weight and health emerged: the obesity epidemic. Boreo (2012) refers to obesity as a “post-modern epidemic,” meaning obesity is constructed as a disease and yet there is no clear pathological basis—despite efforts to find environmental, genetic, neurological, hormonal, and bacterial bases for obesity. As a result, obesity is not fully medicalized.

However, the lack of a clear biological pathology makes the construction of obesity as illness more fluid, allowing for the diagnosis of more people into this category. This partial medicalization combines with elements of moral panic in post-modern epidemics.

Moral panics occur during times of social and economic upheaval when a certain group is seen as a threat to the existing moral order. The level of stigma against fat people has

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risen in the face of the dominance of the obesity epidemic rhetoric. Andreyeva, Puhl, and

Brownell (2008) of the Rudd Center for Food Policy and Obesity found a rise in discrimination against fat people since the early 2000s when the War on Obesity arose. In the aftermath of the 2000s economic crisis, Saguy argues that it’s not surprising that people who are figuratively tightening their belts would look at fat people—the perceived physical embodiments of laziness and gluttony—with disdain (Ortyl 2010).

Obesity and Illness Experience

For many decades, sociologists have been interested in illness experiences. This work arose not only from humanities and social scientific critiques of the dominance of medicine, but also in a context where patients are living longer with chronic illness (Bury

2001; Frank 2013). Patients are not merely passive recipients of medical diagnosis and treatment; instead, they actively shape their illnesses and their sense of self in relation to this illness (Conrad and Barker 2010). For example, Conrad (1985) examined the medication practices of epilepsy sufferers and found that patients actively managed their medication based on the symbolic meaning epilepsy and its treatment carried. For instance, patients might adjust their medication or stop taking it as a way to test and measure their own illness.

One intriguing line of inquiry is the sociological study of embodied experiences and perception. It is difficult to study embodiment given that embodied perceptions are not uniform and are often difficult to describe (Moore and Casper 2015). Following the insights of Goffman (1959), sociologists have noted that perception is an active process involving interpretations filtered through social frames. Through her interviews with cisgender blind people and sighted transgender people, Friedman (2013) has taken a deep

96 look at the way that society filters what we do or do not visually perceive as relevant when evaluating gender. She argues that we not only selectively view difference, but we selectively filter out visual evidence of sameness between male and female bodies.

Likewise, many medical sociologists have noted that perceptions of symptoms and various embodied experiences of illness do not simply represent objective reality, but are filtered through an interpretive process (Conrad and Barker 2010). To understand embodiment, we need to listen to the voices of embodied subjects.

One of the central tenets of fat studies is that scholarship about fat bodies needs to be centered around the experiences of fat people (Rothblum and Solovay 2009). Gailey

(2014) based her work on the ocular ethics (Casper and Moore 2009) of obesity in the stories of fat women. From these narratives, she argues that fat women are hyper(in)visible in the rhetoric around obesity. Fat bodies are such a common subject for debate among medical practitioners, public health literature, media talking heads, etc.

However, the voices of fat women are often missing from these discourses—the lives of fat women are rendered invisible.

A few sociologists have examined the ways in which bariatric patients experience health, illness, and embodiment. British sociologist Karen Throsby (2007, 2008, 2009) has published a number of papers from her interviews with bariatric patients in England and Scotland. Much of her work focuses how patients account for their “moral failings” as fat people previous to bariatric surgery. Patients account for their weight gain and failed weight loss attempts prior to surgery in ways that resist the construction of them as moral failures—by citing issues like their childhood environment or the ineffectiveness of weight loss pills (Throsby 2007a, 2009a). Throsby (2008) also discusses the way

97 patients describe their surgery date as a “rebirthday.” Patients conceive of this day as a

rebirth not because their bodies are suddenly changed from fat to thin. In fact, at this

point patients have typically only lost a little weight from their pre-surgery diets. Rather,

bariatric surgery signals a transformation into a more disciplined body—one that is able

and willing to do the work to lose weight. Patients view bariatric surgery as a technology

which enables this transition.

Boero (2012) included ethnographic work with bariatric patients to support her

argument about obesity as a post-modern epidemic. She notes that even healthy patients

cite concerns about future chronic illness as a reason to undergo surgery. However, based

on her interviews and observations, Boero argues that fat people undergo bariatric

surgery—like all weight loss products and programs—not primarily because of concerns

about health, but instead because of a desire to become normal. Furthermore, Boero

observes that when patients begin the process of undergoing bariatric surgery, they are

assured that obesity is a disease and it is not their fault that their past attempts at weight

loss have failed. Bariatric surgery is sold as a biomedical tool that can facilitate this

weight loss. However, when surgery fails to produce weight loss, patients and

practitioners alike blame individuals for their moral failings rather than criticizing the

biomedical intervention27.

27 I must note that my findings differ from Boero’s in at least one way. In Boero’s argument, successful weight loss from bariatric surgery is seen as a biomedical success, and failure is viewed as a failing of the individual. My findings confirm that failed weight loss or weight gain is most often blamed on the individual bariatric patient. However, my findings suggest that when patients are successful they do frame it as an individual success, not just a successful intervention. Like Drew (2011), I found that patients conceived of bariatric surgery as a tool, but they argued that the results were fundamentally a result of their disciplined hard work. 98 Based on ethnographic data gathered from a clinic in Barcelona, Spain, Porras

(2006) argues that bariatric surgery is not a restorative medical procedure but a body configuration process. Things that would be considered “side effects” in restorative medical procedures, in bariatric surgery represent “a new set of semantic-material relationships” where the body’s (dis)ability to eat large quantities of food and absorb nutrients compels patients to change their eating behaviors.

This paper centers on the subjective health and illness experiences of bariatric patients. I argue that bariatric patients’ experiences of health and illness are filtered through the cultural lenses of health morality and fat stigma. Bariatric patients describe their obese embodied identities as an illness experience which restricts their freedom to move and binds them to medication regimes. These experiences are impacted by the built environment and filtered through moral ideas about fatness and health. After surgery, patients experience certain “bariatric symptoms.” Bariatric symptoms might be considered illness in other circumstances, but in bariatric surgery these symptoms are normalized, viewed as important tools for weight loss, and considered worth it in the end.

This allows patients to construct their bariatric embodied identities as healthy (or at least, healthier than their obese embodied identities) despite the bariatric symptoms resulting from their reconfigured bodies.

Free from the Weight: Obesity as an Illness Experience

In my interviews with bariatric patients, it became abundantly clear that health is a major part of bariatric patients’ experiences. Even healthy young women28 discussed the fear of future health effects as a major reason for undergoing bariatric surgery. What

28 Women in their 40s or younger without diagnosed chronic illnesses 99

was clear is that bariatric patients viewed their obesity as an illness experience. I coded two common ways in which patients commonly discussed obesity as an illness experience: how their weight limited their ability to move, and by counting the number of medications they took. As I examined these codes further, I found that patients often described these illness experiences in terms of freedom—to be sick is the be limited, even trapped. To be healthy is to be free—free from the limits of their large bodies and the medical treatments used to manage them.

Freedom to Move

Patients often describe their experience of health and illness in terms of “quality of life.” When pressed about what they mean by “quality of life,” issues of mobility almost always come up. Feeling ease and comfort moving their physical bodies is an important component of the health and illness experiences of bariatric patients. Feelings of pain when moving, low fitness levels, and the limitations created by the built environment make patients feel trapped in their own fat bodies. Patients discuss their greater fitness, reduced pain, and increased ease in navigating built environments as evidence of improved health. In undergoing surgery, many patients can improve their mobility and fitness, allowing them to participate more fully in life free from the weight of their bodies and the equally heavy burden of fat stigma.

Larry describes the experience of carrying his weight before surgery.

I related to [carrying] sixty-pound bags of concrete. Put one on each

shoulder and walk up the stairs and see how you feel. That was it. You

feel a lot better when you get rid of it. – Larry, 65, white, retired

firefighter and small business owner, 1 year post-surgery

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The heaviness of a very large body combined with other factors such as low fitness levels, injuries, disability, and aging caused many patients to struggle with pain and limited mobility.

When I asked Martin what the word “obesity” meant to him, he replied that pain defined the experience.

Pain. Yeah. I’ll tell you how what, especially when I was in New York,

and I was in the subway a lot, I was in the driveways or when I was flying

a lot, I’d see somebody who was as big as I was and I would say, you

know, that hurts. It hurts—that person is in pain. – Martin, 59, bi-racial

Black and Jewish, lawyer, 5 years post-surgery

Seeing the other fat people carrying weight and crammed into crowded airlines and subways reminded Martin of his own embodied experiences of pain as a fat man.

Patients often described being in a feedback loop where pain prevented them from exercise, which in turn contributed to weight gain. This weight gain increased the pain and made fitness more difficult to achieve. Lucy’s struggle with mobility issues led her to feel that she had no choice but to undergo bariatric surgery to lose weight. Lucy’s mobility improved after bariatric surgery; however, she still cannot engage in much exercise. She tore a tendon in her ankle—an injury that she attributes to “wear and tear” from working for 43 years as a medical technologist. She also developed walking pneumonia after gallbladder surgery29 and continues to struggle with breathing issues from that illness. Illness and injury have contributed to Lucy’s post-surgery weight gain.

29 Bariatric patients—along with other people who lose significant amounts of weight— often develop gallstones and subsequent infections in their gallbladder. Often this means their gallbladder must be removed. Almost all bariatric patients at the clinic have an 101

My knee doctor at least says it’s a double-edged sword, and the funny part

too is he’s gained weight too. But he says it’s double-edged sword. Your

knees hurt and [you] don’t want to exercise. So you gain more weight and

then they hurt more. – Lucy, 66, white, retired medical technician, 9 years

post-surgery

Lucy reports that her mobility is still better than before surgery, but it was clear from our conversation that she is not happy about her weight gain and continued mobility issues.

Fat stigma contributes to this fitness, pain, mobility feedback loop. Fat people are stigmatized; fat bodies are constructed as ugly, dirty, lazy, and gluttonous. Fat bodies are also believed to be inherently unhealthy and their ill health is attributed to poor health behaviors which stem from their flawed moral character. As a result, many fat people feel shame when they are seen visibly struggling with fitness and mobility issues. Before her surgery, Jodie carried an inhaler to manage her asthma. Her weight combined with her chronic breathing troubles made exercising in public a shameful experience.

[I] would try to go hiking with friends. Oh my God. My husband wouldn’t

understand it. I told him, I [am] going to sound like your grandma… I

keep an inhaler in my bag and keep an inhaler at home. But it was more

exercise-induced asthma is what I had. But I mean, my friend who I

walked with, she would be like, “Are you okay?” I’m like, “Yeah… I’m

all right.” But I would just wheeze so bad. It was embarrassing… I mean a

ultrasound done on their gallbladder to check for stones before surgery. The clinic requires many patients to have their gallbladder removed before bariatric surgery as a preventative measure, especially if stones already exist in their gallbladder. That means that many patients must undergo multiple surgeries and can develop food sensitivities as a result of both procedures. 102 couple of times, [I] was really to tears, because… I’m sweating, nobody

else is because I was overweight and nobody else is. Then I’m wheezing

and I couldn’t keep up. I told my husband I don’t want to go out with

them. I said, “I am so embarrassed.” Because when we go in this hard trail

and I felt like I couldn’t do it. I just felt, I don’t know. I just didn’t feel

good about myself. I really didn’t. – Jodie, 59, white, education assistant,

3 years post-surgery

Before losing weight from bariatric surgery, Jodie avoided these hikes with friends and

family. After losing weight from surgery, Jodie felt less shame hiking and exercising. She

reported feeling comfortable enough to take fitness classes without worrying about her

visibly fat body. Now that she is free from the discredited identity of being a fat woman

visibly struggling with exercise-induced asthma, she regularly walks, hikes, and takes

fitness classes with friends and family.

For some patients, fitness is an important part of their identity after bariatric

surgery. For instance, Pete and Kate cofounded an organization dedicated to hiking in the

local parks. Kate (41, white, Medicare reimbursement specialist, 5 years post-surgery)

became an avid hiker after her surgery, hiking regularly even into the coldest winter

months. She even met her fiancé through their local hiking organization. Pete (61, white,

data architect, 7 and 2 years post-surgery30) trained for a half marathon and bikes many

miles every week. When I spoke with him, he was contemplating retirement and

fantasizing about a cross-country bike trip. Because of his strong fitness identity, Pete

30 Pete had a Lap Band placed on his stomach 7 years ago and then had the surgery amended to a full gastric bypass 2 years before the interview. 103 became a literal poster child for the bariatric clinic: his image has been featured on the clinic website, pamphlets, and other advertising.

For some patients, fitness is an important part of their identity even before surgery. In her youth, Amanda was an athlete. Later in life she developed asthma, which limited her ability to exercise. In fact, she had to change careers from working in construction to working as an administrator for an adult education program—a much more sedentary working environment. To treat her asthma, Amanda’s doctor placed her on steroids, which contributed greatly to her weight gain. In addition, Amanda has faced serious personal challenges, including the death of her young adult son—her only child.

She serves as a caretaker for her elderly mother, developmentally disabled step-brother, and an elderly “gentleman friend.” Given the medical and personal challenges that

Amanda has faced in the past decades, it is not surprising that she has gained weight and lost her previous young, athletic, fit identity. More than she wanted to lose weight,

Amanda wanted to experience the joy she felt in vigorous exercise in her previous fit embodied identity. During our interviews, Amanda discussed at length how she longed to feel “the burn” of strenuous physical exercise. When I spoke to her after her surgery she was beginning to feel those sensations from exercise again.

It’s been wonderful. I’ve been able to go up those steps and I’ve been able

to, like, little trot up the steps a little bit and I’m like, wow, this feels good.

I mean because before I would get up there and I would really just

struggle. Not just with my asthma but it would mess with my confidence

as to could I do this again because I know before this was something that,

that burn was something I desired. Most athletes like pushing yourself,

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burning that was like, okay, you’re getting high. I would go up half of

those steps and I’ll be like, this is not working, this is hurting and this is

not a burn. This is, like, awful. Now I can feel going up the steps is a little

bit more freedom and I feel better and I think my lungs are going to

appreciate it too. – Amanda, 50, Black, G.E.D. program facilitator, 4

months post-surgery

Healthy eating and fitness were important parts of Kim’s identity even before bariatric surgery. Aside from her weight31—which Kim viewed as unhealthy and inevitably leading to illness later in life—Kim was quite healthy and health-conscious in her behaviors. In fact, Kim has worked as a nurse and, at the time of our interview, attending graduate school to become a nurse practitioner. Even though Kim has a very healthy and active lifestyle, she still feels there are things she cannot do because of her weight.

I fully can look at the changes that are going to come for me and getting

excited about it and looking forward to things that I can’t do now, and I’m

not a person to hold back. I just suffer because of my weight but there are

things I cannot do because of my size. Looking forward to those things, so

I have made, like, a list of things. – Kim, 44, white, graduate student, pre-

surgery

When I asked Kim what was on her list, she told me that she wanted to try zip lining, ballroom dancing, “aerial skills” (a type of aerobics done on fabric hanging from the

31 Kim believes that her weight is related to mental health issues as well and attributes underlying psychological and intimacy issues with her weight. She also describes certain dieting practices—such as counting calories—as “triggering” for her body image issues. 105 ceiling), joining the local rowing club, and wearing high heels with less pain. For some things, her heavy body presented a problem. For instance, in aerial skills you must have the upper body strength necessary to hold your body up, which is difficult for a person weighing over 200 pounds. Many women—fat or thin—experience pain when wearing high heels, but this pain and pressure can be greater for women of size. However, many of the other things on Kim’s list are problems arising from the built environment. For instance, when I talked to Kim after her surgery, I asked if she had begun doing things on her list.

I need to be smaller yet. Because, like, for rowing club I need to be small

enough to fit in the boat and slide in the boat without shaking. Because I

think I just need to be smaller enough and strong enough to be able to do it

comfortably. – Kim, 44, white, graduate student, 1 month post-surgery

Kim reported losing some muscle after surgery. Other participants reported the same experience. The weekend before surgery, Kim went kayaking for 2 hours, but after surgery she felt her muscles were not strong enough to do it. She feels confident that she can rebuild her strength.

Aside from the strength issues, the other problems Kim has with her size are related to the built environment. Fat people of a certain size cannot comfortably engage in many exercise activities—such as rowing—because boats, along with other outdoor or exercise gear, are often nearly impossible to find in larger sizes. Like Kim, many patients struggled with a combination of issues of fitness and mobility as well as trouble navigating the built environment.

106 Especially before the surgery I could not get out of my house that much…

I mean, I couldn’t sit in a movie theater seat... I remember this last year we

went to a [professional basketball] game when my brother came home for

Christmas and I’m, “Oh my gosh, I fit in the seat!” Because two years

before that we went to a [basketball] game and I was so uncomfortable in

those seats and I’m, my legs are falling asleep and all this stuff. Not only

could I walk up the stairs to where our seats were, because we were the

last row, but it was like, you know what? I can sit in this seat and not feel

weird and it was really cool. – Kelly, 29, white, unemployed and disabled,

2 years post-surgery

For Kelly, her increased fitness made it easier to ascend the stairs to get to her seat in the basketball arena. Also, Kelly felt more comfortable sitting in a seat that actually fit her body. This comfort is not just about the physical comfort of not having to squeeze into a seat that doesn’t fit her body, but also about not feeling “weird.” Fat people often feel embarrassed when sitting in spaces that don’t fit their bodies, worrying that others seeing their overflowing flesh and obvious discomfort are judging them as ugly moral failures

(Hetrick and Attig 2009; Stevens 2017).

Patient mobility issues are medicalized; patients are undergoing a medical procedure to solve these problems. That’s not to say that these mobility issues don’t in many cases spring from embodied impairments that come with age, injury, low fitness, and illness. However, like disability, for fat people their impairments become disabilities through the environment. The cultural environment of fat stigma is manifested in the built environment. Fat people often internalize issues of fitting in and the stares and judgments

107 they perceive in these spaces—further individualizing and pathologizing a problem that

stems from an environment designed to serve the young, thin, and not (yet) disabled

(Aphramor 2009; Herndon 2002; Stevens 2017; Wendell 2015).

For many patients, carrying a healthier embodied identity after surgery was not

about being a fitness buff or an athlete. Instead, health is about functioning as a “normal,”

able-bodied person in daily life.

I feel like going up on bike again, I can do what I want to do. I was kind of

a prisoner before because I couldn’t do anything. I literally couldn’t do a

lot of things around the house. I couldn’t. We like to travel and we travel a

lot with our kids. I couldn’t walk around the city for half a day. My son

got married last year and we spend hours in Nashville walking all over the

city, and I couldn’t have done that 3 years ago. I feel like I’ve gotten my

life back as far as just being able to do kind of normal forms, nothing

extraordinary in the physical sense, but just what’s normal things I can do.

It’s wonderful. It’s freeing. I just feel healthier and I just feel better. –

Harriett, 57, white, nurse, 2 years post-surgery

For Harriett, health is about being able to enjoy life with her family. She feels more able

to engage in day-to-day “normal” activities. She describes her obese embodiment before

surgery as a prison.

Some patients described feeling that their lives were not worth living before

bariatric surgery32. This is especially true for older individuals who were so immobile

32 Seven patients expressed this feeling about their own lives. Two patients expressed this sentiment in worrying about the quality of life of their children or grandchildren. 108 that they had to use a walker or a wheelchair to get around. Luke struggled with a lifelong

genetic condition. During his childhood, his parents were told he would never walk.

Despite this, Luke was able to walk in his younger years and he even ran a machine shop

with his brother Bob33. As Luke got older, his disability continued to become a problem.

This was compounded by unhealthy behaviors—including smoking—and his growing weight. Luke describes a litany of modifications he made to his truck and home to accommodate his diminishing mobility—all costing very large sums of money. By the time he chose to undergo surgery, Luke was using an electric scooter, and he was too heavy for the wheelchair lift in his van and too disabled to get the scooter up a ramp.

It was just between being handicapped and being heavy and not being able

to move around and stuff. You get to the point where, why am I even

living? This is not worth it. It’s just not worth it. So then I got to the point

where, God, I got to do something. I’m trying all these ways around

working with what I got. – Luke, 61, white, retired machine shop owner, 1

year post-surgery

Luke had felt he had reached the limits of what he could afford to do to increase his mobility without losing weight and addressing his health issues34. Like Lucy and other patients, Luke felt that he had exhausted all of his other options and had to do something to lose weight.

For most patients, health and illness are defined in terms of pain and mobility. If we live long enough, all bodies will experience pain, injury, illness, and aging. For

33 Also interviewed for this study. 34 He told me that his doctor “gave up on him,” telling him there was nothing more that could be done if Larry wasn’t willing to change his health behaviors. 109

people who carry large amounts of weight, there can be unique challenges to managing this inevitable loss of physical ability. Physical impairment is a part of this story for most patients. However, if we look at these accounts of bariatric patients, we can see what disability scholars have been arguing for ages (Conrad and Barker 2010; Wendell 2015): physical impairments become disabling when placed in a social and built environment which privileges “normal” bodies and stigmatizes deviant bodies.

Freedom from Medications

Patients often reported taking a number of medications to treat chronic illnesses including diabetes, acid reflux, high cholesterol, arthritis, etc. Medication not only treats these illnesses and their symptoms, but also comes to be a symbol of the illness itself

(Conrad 1985). One of the most common perks of bariatric surgery that patients discussed was removing medications. In many cases, bariatric patients go into remission from chronic illness after surgery—especially diabetes35.

When I spoke to Amanda before her surgery, she told me that she was looking forward to being “free from the medications.” I asked her what she meant by this.

It’s more or less, there is always no guarantee but one of the things that the

bariatric surgery would free me from would be all the diabetes

medications and Nexium, which is a medication for upper gastro, gut or

acid reflux. That medication is very expensive, so hopefully I’ll be free

from those medications after the surgery… plus I’m 50. I’ve been battling

35 While diabetes commonly goes into remission with bariatric surgery, some people remain diabetic even after surgery. Many patients who continue to live with diabetes after surgery note that their prognosis is improved but feel disappointed and even cheated when the condition doesn’t totally go away. Patients report that physicians at the clinic tell them their diabetes will go into remission in more certain terms. 110

these diabetes and illnesses for about 10 years now. I’m at a point where I

think it’s time to change around and if I’m here another 15-20 years, I

really want to give it all my all as far as health, diet, exercise and continue

living freely in my own body, because it’s been hard being in a body that

doesn’t feel like your own. – Amanda, 50, Black, G.E.D. program

facilitator, pre-surgery

For Amanda and many others, bariatric surgery offered freedom from the cost of the medication. Also, Amanda is equating freedom from medication with freedom from her struggles with illness.

Medications often carry unpleasant side effects and sometimes contribute to weight gain. Several patients report being placed on steroids for medical issues and struggling with weight gain as a result. Amanda’s struggles with medication started when she was diagnosed with asthma and put on a steroid treatment. Other patients had similar stories. Jane’s terrible pain issues began after brain surgery when she was placed on steroids. The weight she gained put pressure on her sciatic nerve, making it painful to walk down the block. Larry took steroids to treat his genetic disability, which lead to weight gain and diabetes. Darcy was placed on steroids after a near-fatal allergic reaction to a migraine medication which contributed to her post-surgery weight gain.

Amanda struggled with the effects of her medication during her pre-surgery process. She reported having a mental breakdown over the difficulty she had with taking her medications to manage her asthma and following the prescribed diet regimen during the pre-surgery process.

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I tried not to take my medication, because I wanted to lose weight. Even

though in my mind I knew I still didn’t want to, didn’t take it, until I got

sick, and I had a meltdown and then the next one, the component of

mental, mind, body and all that goes together. I had a mental breakdown

too, because I was upset, because I was fearing, “How am I going to lose

weight, how am I going to do this?” I really didn’t have any support. I

took the medication and I weighed in. The first time I weighed in the lady

said to me, “You are not going to have surgery unless you lose weight.”

That upset me because I’m on these steroids, I have to eat, and I don’t

know how to do this and you can’t exercise, you [have] asthma, your chest

is hurting, you can’t do nothing. I was upset, and then unfortunately I had

another asthma attack, and I waited, but then I took the medicine. Then I

just kept going, by the 3rd asthma attack I was like, whatever, I’m going

to keep doing what I’m doing, keep preparing those low [calorie] foods,

because by the end I’ve learned a few nutritional things. Then I’ve learned

to just try to exercise as much as I could, and it all worked out. If I get sick

I’m taking the medicine, I’m not tripping anymore. – Amanda, 50, Black,

G.E.D. program facilitator, pre-surgery

As discussed in chapter 3, bariatric patients must undergo six months or more of pre- surgery testing, classes, and appointments. During this time, patients must prove that they are capable of losing weight. In fact, any weight gain—even a single pound—is grounds for dismissal from the bariatric program. Amanda felt that the clinic placed her under

112 pressure to lose weight but did not provide her with the support and resources she needed

to lose weight while also maintaining her medication regimen.

In addition to the high cost and troubling side effects of medical treatment,

medications also represent illness symbolically (Conrad 1985). Being prescribed more and more medications is a potent symbol of worsening health. Likewise, removing those medications one by one symbolizes a return to health. One of the most common ways that post-surgery patients described their move from poor health before surgery to improved health after surgery was by counting down the number of medications they no longer had to take after surgery.

From having that surgery, like I said I was on insulin 4 times a day, I don’t

take anything for diabetes anymore. No insulin, I don’t take no pills, my

sugar never goes over 100. Now I have been having some problems lately

that my sugar had been dropping and it was because I was still trying to

lose more weight… I don’t take anything for diabetes anymore. I don’t

take any medicine other than vitamins. That’s all I take and I had sleep

apnea real bad, I don’t have that no more. I don’t use the machine

anymore. I had bad cholesterol I think since the day I was born it seems

like, but I don’t take nothing for cholesterol anymore. I don’t have any

problems there and I said it’s just amazing what this surgery does, like I

said there is nothing easy about getting to that point. – Luke, 61, white,

retired firefighter and small business owner, 1 year post-surgery

Removing the medication and other medical treatments (i.e., the c-pap machine for sleep apnea) is a clear sign of remission from illness and improved health. This shedding of

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these medications is not just evidence of clinical improvement, but also represents a symbolic exit of the illness that the medications represent.

Bariatric patients take many vitamins and supplements. Bariatric surgery modifies the way the digestive system works, limiting absorption. This is particularly true with the most common form of bariatric surgery, the Roux-n-Y or gastric bypass procedure, where the upper part of a patient’s small intestine is removed. This means that bariatric patients are compelled to take supplements and get regular blood tests to determine if they are receiving adequate nutrition and adjust their diet and supplement regimens accordingly.

For most patients, taking vitamins does not carry the same symbolic weight as medications associated with illness or pain. While many patients counted down their other medications as a sign of health, the number of actual pills they took often stayed the same or even increased.

But the medications that I have been able to [stop taking], easily added

supplements or something to take the place for pill for pill. I’m still taking

many pills. But those that [my doctor] has got me on, I will eventually be

able to take them off. Hopefully with that, I will drop maybe 30% of the

medications maybe. – Joe, 64, white, retired dairy plant supervisor, 5

months post-surgery

While Joe hoped to remove some medications, including supplements, from his regimen, other patients acknowledged that supplements would be a part of their day-to-day life from surgery forward. Laurie described being informed of this early in her bariatric career before she had decided to undergo surgery.

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I had to talk to the nurse and the dietician about all [bariatric surgery]

would entail, and I’ll be on supplements or pills for the rest of my life. I

have vitamins, basically vitamins. – Laurie, 73, white, school secretary, 2

years post-surgery

While patients are taking a great deal of supplements to manage their reconfigured bodies’ malabsorption issues, their reconfigured bodies do not allow patients to take these pills all at once. There are a number of rules on how many vitamins and what sorts of supplements a person can take together at a time.

I have a little alarm on my clock, my phone and in every 2 hours it goes

off. I take vitamins every 2 hours until I’m through with today’s

vitamins…you have to space things out like the calcium, you can’t take it

all at once, and you have to take it out throughout the day. You have to

space it up by 2 hours. So you can’t take any other mineral with calcium.

So for, like, iron, you can’t take it or zinc, you can’t take it at the same

time as your calcium… I just kind of space everything out every 2 hours.

My phone is supposed to ring every 2 hours and at least 2 hours and in-

betweens, so every 2 hours. So if I miss one of those 2 hour periods I just

pick up at the next one. – Joanne, 56, white, accountant, 4 years post-

surgery

Not all patients were as successful as Joanne at taking supplements in an organized and regimented way. For some, it was difficult to manage these regimens with a busy work and family schedule. Some patients had relatives (almost always women relatives) help them manage their nutrition. For instance, Larry’s and Bob’s wives

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managed their supplement regimens and Laurie’s daughter helped her. For Kelly, she found it overwhelming to take her supplements along with her psychiatric medication.

I’m like, you know what? I’m on so many pills at once, the psychiatric

drugs and others. I have problems with my thyroid and my body

technically killed it off and so I take Levothyroxine. I could give you a list

of the pills I take, actually, but it’s funny because you can only take 2

every 20 minutes and at night that’s an hour-long procedure for me and

during the day I actually take 3 and then wait 30 minutes then because the

third one is a little one and then I take another 3... [clinic staff] didn’t tell

me anything about this before the surgery, they just told me I’d be able to

take more pills… [after surgery] they are, “Oh no, you can only take 2

every 20 minutes,” I’m, oh God, do you know how many pills I take?! –

Kelly, 29, white, unemployed and disabled, 2 years post-surgery

We can see that freedom from medications does not mean freedom from the rituals of taking medication. For many patients, their medication practices have become even more complex and regimented.

While supplements do not carry many of the side effects that other medications do, they are not totally without risks and side effects. Delphine struggled with kidney stones from the calcium supplements she took.

I will say that part of the vitamin therapy is, you’ve got to take calcium.

The easiest way to diet just calcium is to eat Tums. So I had been throwing

4 Tums a day into my system. Which will help kidney stones… so, backed

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off of that for a while. – Delphine, age 55, woman, white, 3 months post-

surgery

With all these supplements, one has to wonder: are bariatric patients truly free from medication? While medication is an indication of chronic illness, in many ways supplements are a treatment for a digestive system that is permanently altered to disable its ability to absorb nutrients. Their required blood work to check their nutrition means they are not free from the surveillance of the medical gaze. They must continue to follow the ritual of taking supplements, spacing them out with meals, in many cases taking as many tablets as they did before, if not more. They are no less dependent on these supplements than they were on medication; if they fail to take them, their health will suffer and they could lose hair, nails, and even teeth. While they don’t encounter the same degree of side effects, they are not completely without risk, as Delphine’s experience with kidney stones demonstrates.

What patients are really free from when they stop taking medications and start taking vitamins and supplements is the symbolic connection to illness and stigma that certain medication practices carry. While medication taken for blood pressure, cholesterol, diabetes, or pain carries the symbolic weight of illness, supplements and vitamins are things that “normal” or “healthy” people take to optimize their health

(Conrad 1985). As a result, vitamins carry a different moral weight. Because the chronic illnesses patients carry are associated with fatness, which is believed to be the result of poor health behaviors, patients feel shame and blame for their illness. Vitamins, on the other hand, are part of an embodied project to enhance and optimize health. Such projects

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are viewed with a positive moral light in our society. They are signs of self-discipline and keeping us with the moral value of health (Metzl and Kirkland 2010).

What’s clear from the accounts of bariatric patients is that before surgery most bariatric patients experienced their weight as illness36. This experience is characterized by feeling trapped by pain and low fitness in bodies that do not fit into the built environment. It is characterized by feelings symbolically bound to medications and other treatments for chronic illness. Even for patients who do not experience chronic illness, the fear of future illness and the desire to be healthy means that health and illness remain central in their accounts. But this presents a paradox: the desire to be free from illness (or the possibility of future illness) drives patients into a disciplinary program which demands near-total control of their day-to-day lives (see chapter 3). One of the ways this control is accomplished is by fundamentally altering patients’ digestive systems in ways that often produce feelings of sickness in the body.

Healthy but Sick: Patients’ Experience of Bariatric Symptoms

Bariatric patients experience a number of unpleasant sensations after surgery, which I refer to as “bariatric symptoms.” Patients commonly assert that “everyone is different” in terms of how they experience bariatric symptoms after surgery, and I found variation in terms of which symptoms participants reported as well as the intensity, frequency, and duration of symptoms. The most common of these bariatric symptoms are upset stomach, intense pain in lower esophagus, diarrhea, constipation, nausea and vomiting, gas and stomach rumbling, sensitivities to certain foods, changes in the way

36 Patients varied in whether or not they believed that all fat bodies were ill. But even those who believed people could be fat and healthy did not view their own bodies as healthy. 118

foods taste, feeling cold and having trouble getting warm, and a condition called dumping syndrome or just “dumping.” Dumping syndrome occurs when a bariatric patient consumes too much sugar or fat, which results in nausea, vomiting, diarrhea, feeling hot, sweating, and dizziness. Other patients reported trouble consuming water, malnutrition, loss of muscle mass or weakness, hormone changes impacting emotions and menstruation, hair loss and nail brittleness, heartburn, alcoholism, and gallstones.

To a person whose digestive system has not been surgically modified or to someone whose digestive organs were surgically modified for other reasons—for instance, to remove tumors on the stomach or intestine—these symptoms would likely be interpreted as a sign of illness or disability. For bariatric patients, these symptoms are not conceived of as illness—most bariatric patients experience their post-surgery bodies as healthier than their pre-surgery bodies. Patients normalized bariatric symptoms by framing them in 4 ways: 1) as temporary symptoms which will subside with healing; 2) as something to adjust their behaviors and routines to accommodate; 3) as a useful disciplinary tool; and 4) as worth it in the end to achieve weight loss.

Bariatric Symptoms as a Healing Process

Bariatric symptoms are strongest in the period immediately following surgery; they usually remain for about a year after surgery. Beverly was reassured by a coworker who had undergone surgery 5 years prior that she would eventually be able to eat foods that she could not in the beginning.

[My coworker] said… at that point she could pretty much eat anything she

wanted. I mean, she was eating a candy bar the one day. She said, "I don't

eat the whole thing." But she said, "I can have a few bites of it and I'm

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ok." She said, "But 5 years ago, I couldn't." She said, "5 years ago, I'd

have been hurling." So, and that's something they tell you too, is to not get

disappointed if, say, for instance you can't eat your favorite food in the

world within the first couple years. Because your tolerance could change

over the years to where another year you might be able to tolerate it. So

they said, “Always go back and revisit things that you couldn't tolerate in

the past if it's something that you like and see if you might be able to

tolerate it now.” That's something that I definitely want to keep in my

mind because there are some things that I like. – Beverly, 48, white, bank

loan specialist, pre-surgery

During the first year or so after surgery, patients engage in a process of testing whether or not they can consume certain foods. Charlotte and her sister Dolly37 explained how

Charlotte slowly incorporated eggs back into her diet. Periodically she would try and eat eggs, but she would “know instantly” when her body wasn’t ready to consume certain foods like eggs.

You feel horrible… it was just like, I can’t do this. Then I’d wait a month

or 2, and I would try it again, because eggs was what the big problem was,

but I can do eggs again. – Charlotte, 53, white, disabled former

accountant, 1 year post-surgery

37 Charlotte cared for her older sister Dolly—both have genetic, degenerative eye conditions and Dolly is nearly blind. The two are many years apart in age—in fact, I mistook Dolly for Charlotte’s mother when I met them at the clinic. Both live on disability and spend all their time together. 120

Especially early in the process, patients easily attribute bariatric symptoms to the healing process. They are trained at the clinic to slowly incorporate more foods and to experiment with different types of food (for more information about this process, see chapter 3).

Eventually, bodies heal and adjust to their reconfiguration, causing the most troubling and disruptive symptoms to go away. However, for many patients these symptoms never fully disappear, so they must adjust their own behavior and strategize how they will manage them.

Bariatric Symptoms as Something to Adjust to

Bariatric symptoms are often disruptive and embarrassing, so patients must find ways to adjust their lives to accommodate their reconfigured digestive systems. Like many bariatric patients, Bob has difficulty digesting meat. He discovered a workaround that allows him to enjoy one of his favorite foods, steak.

You eat one bit of [steak] and it doesn't want to go down, even though you

chewed and chewed and chewed. Well, what I do and because I love steak,

I'll chew and chew and chew and chew and then I'll just take it out of my

mouth and set it on my plate… I swallow all the good flavor, you know,

and it doesn't take up any room in that little pouch of mine. But I like steak

and it's hard for me to give up. But it just doesn't agree with me. – Bob, 67,

white, retired business owner, 3 years post-surgery

Erma years after her bariatric surgery continued to experience emergency diarrhea. She described strategically mapping out where she could use the restroom en route to and from the places she frequents.

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I have a place between there and where I work out where I go to the

bathroom. It's a really clean, nice bathroom… yesterday I was in such a

hurry. I went in, the door closed, and I thought, “Hmmm...” I was in the

men's room… I saw the urinal and knew I was in the wrong restroom. So I

went out. I made it. It was tough making it. You know. – Erma, 75, white,

retired realtor, 6 years post-surgery

Erma described other incidents where she didn’t make it—notably one where she and her son were stopped in traffic because of road construction. Her son told her, “Just go. We’ll clean it up at home.” For the most part, Erma is hyper-aware of where she can stop and use the restroom during her daily activities.

As Erma’s story indicates, many bariatric symptoms are embarrassing. Bariatric patients seek to control their bodies in terms of their weight, but in the process often at least temporarily lose control of their bodies’ digestive functions. Patients must learn to manage these symptoms to limit their embarrassment. Gas and stomach gurgling is common after surgery. Ellen describes discussing these issues in the bariatric support groups.

I was one of the ones asking this stupid question, “Why does my stomach

make all these weird noises? Growling noises and after I eat it’s like a

rhythmic movement.” People just laughed and they said, “Oh yeah,

everybody within 6 feet of me knows you’ve been eating.” It was funny

because the dietician said, “I didn’t know that.” It was like we taught her

something… I will be sitting there and my stomach will make some weird

noise, I say, “Oh my God, did you hear that?” It’s like, yeah, everybody

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heard it… it’s embarrassing if you are out in public. You just learn to

laugh it off, be a duck, let it roll off your back. – Ellen, 62, white, retired

social worker, 1 year post-surgery

With many symptoms, patients have to learn to manage their embarrassment. For Ellen, having a supportive community of other bariatric patients helps her to laugh off her embarrassing gas and stomach gurgling.

Bariatric Symptoms as a Disciplinary Tool

While bariatric symptoms are often painful and embarrassing, patients are often disappointed when these symptoms fade away. That’s because these symptoms are most often framed as disciplinary tools. In fact, patients often refer to bariatric surgery as “a tool” for weight loss and often refer to the bariatric symptoms as “tools” or

“restriction”—referring to the ways in which these symptoms restrict their ability to eat certain foods or too much food. It’s this “tool” that bariatric patients (and practitioners) assert is the reason why bariatric surgery is an effective form of weight loss where most diets and weight loss programs fail. Bob compares bariatric surgery to another common medical weight loss intervention, Optifast, a high-protein liquid diet.

I'd say anybody could lose weight on Optifast but it's real expensive. But I

think they're going to gain it right back… but the bariatric surgery, you're

not going to gain your weight right back. You're going to gain it back if

you want or you're not going to gain it back right away. It’ll actually kill

you to try and gain it back right away. – Bob, 67, white, retired business

owner, 3 years post-surgery

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For Bob and many patients, the key difference between weight loss techniques they have tried in the past and bariatric surgery is the bariatric symptoms. Overfilling the stomach immediately after surgery can result in serious injury and even death—for instance, the stomach can rupture. Even after the body begins to heal from surgery, the painful, uncomfortable, and sometimes embarrassing symptoms of the surgery prevent patients from cheating on their prescribed diets by punishing them when they eat too much or eat certain foods.

They have, like, 3 nutrition classes that I’m going ahead and take, because

you can’t eat, like, the stuff they took away [during the pre-surgery

process], but it caused the dumping and I don’t like being sick either way.

I don’t want to throw it up or poop it out, so it’s something that I’m going

to have to stick to and this is what I need, because you always cheat if you

get a chance. This is stopping me from that, that’s the push I needed… I

know there is no out… I can mess it up but I’ll be sick all that time and

who wants to do that? – Marlene, 47, woman, Black, retired medical

assistant, pre-surgery

Marlene chooses to continue to pursue bariatric surgery because her body will be surgically altered so that she cannot decide to quit the bariatric diet. And if she cheats or

“messes it up,” her body will punish her. For many patients—especially those who had undergone gastric bypass—“dumping syndrome” or “dumping” serves a disciplinary function. Symptoms of “dumping” vary from patient to patient, both in terms of the severity and the specific symptoms they experience. In general, patients report racing

124 heart, sweating and feeling hot, vomiting, and diarrhea. These symptoms occur when patients consume too much sugar, carbs, or fat—most often carbs and sugar.

Given how unpleasant and potentially embarrassing dumping syndrome can be, patients sought to avoid dumping. Jane brought up her fear of dumping frequently.

This is off topic, but Rosie O'Donnell, she was on TV talking about her

surgery. She had the sleeve. She said that [she didn’t have gastric bypass]

because she was scared to death of the dumping syndrome. I was like oh my

God, I hear you, sister. I’m right there with you. Just the thought of it scares

the living daylights out of me. – Jane, 44, white, unemployed and disabled,

pre-surgery

Stories about dumping such as Rosie O’Donnell’s had Jane feeling anxious about the possibility of dumping. Marlene and Jane’s stories show how even pre-surgery patients learn the lessons of dumping through the clinic, the media, and other bariatric patients.

Jane’s anxiety deepened her resolve to enact the self-discipline required by “the program” to avoid dumping.

Like I said, the whole dumping thing has got me a little worried. But I just

have to be very careful. I am going to keep a documentation. I’m going to

journal everything because that way I know I’m not going to [get] caught

going, oh my gosh, what caused me to do that? Because I have thought

about that. I thought okay, well, how are you going to know? I mean you

are going to really have to watch, write every single thing down that you

eat and how your body reacts to this, so you know what you can do and

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what you can’t do. – Jane, 44, white, unemployed and disabled, pre-

surgery

This description of closely monitoring food intake is common among bariatric patients.

They track their food not only to keep an eye on nutrients—especially protein—and calories consumed versus calories out, but also to note which foods caused them to experience dumping or other sickness.

Learning to listen to this heightened sense of fullness is one of the central disciplinary functions of the modified digestive system. Patients often describe the feeling of eating too much, too fast, or certain food as “sitting like a brick/rock.” They describe a pain most often in the upper stomach or chest (esophagus).

Once my body was full it was a done deal. I'm done, I'm full, I can't eat no

more. And if I eat too much, you know, that last bite that everybody wants

to clear your plate. If I ate that I'd be crawled on the couch moaning and

I'm like no, I don't want to do that. That last bite will go to my dog. –

Diana, age 57, woman, Black, janitor, 3 years post-surgery

Some patients will throw up (either by choice or not) to relieve the pain. Others describe having to lie down and wait for the pain to pass. Bariatric surgery provides a hypersensitivity to fullness and certain foods which functions to control patients’ eating habits.

The disciplinary nature of bariatric symptoms is not limited to symptoms which cause pain or sickness in the body. Other symptoms, such as hair loss, convey disciplinary messages about managing food and nutrition. Gabby’s mother-in-law

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underwent bariatric surgery after Gabby. Her mother-in-law struggled with hair loss after her surgery.

You know, like, when she first… she was, like, having a hard time because

she was losing her hair really bad and I'm like, “Ok, now here's why, you're

takin' your biotin every day and are you getting your protein in? If you're not

getting your protein in, that why your hair is falling out.” I said, “You have to

drink your shakes,” and so she started really upping her protein and it helped.

– Gabby, age 50, woman, white, retail worker, 1 year post-surgery

Gabby, like other patients, described seeing visible symptoms of malnutrition—primarily hair loss—as a sign that someone needs to increase their monitoring of the diet. The blame is not placed on the surgery for limiting the body’s ability to absorb nutrients but on the patient’s inability to manage their reconfigured bodies. Other patients, through sharing stories of their own struggle and through mentoring their fellow patients, reinforce these narratives, focusing on how patients can discipline their eating and supplement-taking behavior.

Even though bariatric symptoms are disruptive and embarrassing, these symptoms are often missed when they are absent. Delphine (age 55, woman, white, administrative assistant, 3 months post-surgery) experienced relatively few symptoms immediately after surgery. She was even able to eat a bite of her husband’s soft serve ice cream during her recovery with no adverse effects. Delphine described this lack of symptoms as “both good and bad.” On the one hand, she didn’t have to deal with the pain, discomfort, and embarrassment that come with many of these symptoms. On the other hand, she

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attributed her slow progress in terms of weight loss in part to her lack of bariatric symptoms.

Bariatric systems are imperfect disciplinary tools and sometimes can be counterproductive towards managing a healthy diet. Lucy discusses the inconsistent nature of her food sensitivity. Her sensitivity to sugar had in the past kept her from consuming sweets. Moving forward, she feels less sensitive to sugar and has developed workarounds to consume sweets by doing it a little at a time. Lucy went on to describe food sensitivities that she’s acquired in part because her gallbladder was removed as a result of her bariatric surgery.

I think that’s more for my gallbladder than it is for my gastric bypass,

because when you go further out, it doesn’t bother you than it used to. It is

not the threat that it was at one time, and that is not good. But now I

noticed since I had my gallbladder out in December, there are lot of things

that I can’t eat. Unfortunately, one of them is salads… usually it’s

something that I shouldn’t be [eating]. As far as throwing up, it doesn’t

have to something that I shouldn’t have. It could be anything. Most of my

problems are with meat, after it’s been on the refrigerator and you heat it

up, it doesn’t have the same texture. It’s heavier and denser and if I eat too

much too fast, I start getting the sneezes, I sneeze. That’s how my body

reacts to it. – Lucy, 66, white, retired medical technician, 9 years post-

surgery

Sensitivity isn’t limited to “bad foods” like sugar, carbs, and fats, but also can include

“good foods” such as salads. Meat sensitivity is very common among bariatric patients—

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which is unfortunate given that bariatric patients are encouraged by clinic practitioners to focus on taking in ample amounts of protein.

In the narratives of patients who manage to maintain that weight loss, paying attention to their bariatric symptoms seems to play a key role in their success. Ellen described being grateful that her bariatric symptoms remained when I asked her if she still experienced sensitivity to certain foods.

Yes, as far as I can tell it will probably be that way for a long, long time

because you just never know and I’m glad, some people say that they feel like

their palate or tool whatever you call it …stops working after a while and they

can start eating more stuff. I find I eat more stuff that I used to but mine

definitely still works. I still dump if I eat too much or too fast or the right

things, so. – Ellen, 62, white, retired social worker, 1 year post-surgery

Restrictions and sensitivities will fade as the years go by. As discussed earlier, it is an inevitable effect of bodies’ natural healing process. This is not entirely a welcome return to normalcy. Instead, it marks the end of the “honeymoon phase” of rapidly losing weight after surgery.

Patients commonly expressed the belief that weight regained after surgery is a result of “stretching the pouch”—that is, filling their modified stomach to the point that parts of it stretch to a larger size. Luke found his weight loss stalled and he worried that he had somehow stretched his pouch out.

But now with the surgery I think I have stretched my pouch because I can

eat more. I go to the support groups and people still are only eating a

couple ounces of food at a time. I eat a whole lot more than a couple of

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ounces and I’m thinking I must have really screwed myself up eating too

much and I’m bothered right now because I haven’t lost any weight. The

last time I went to my 1-year visit I’d lost weight but nothing like I wanted

to lose. In the beginning you lose a lot, big leaps at a time. Well, now if I

lose a couple of pounds a month I’m lucky. Well, that doesn’t give you the

excitement to keep going and Doctor D says that’s normal and once you

hit a certain spot, you are pretty much going to stay there. – Luke, age 61,

man, white, retired small business owner, 1 year post-surgery

Luke had reached a plateau in his weight loss, something his surgeon assured him was normal. But Luke still blamed himself. From the period immediately following his surgery, Luke struggled with appetite.

I still have this mental thing that I have to eat more, it just won’t let me

and I don’t know why that is… I don’t know why, I go to these support

meetings and I hear these people are still eating 2 ounces and stuff like this

at a time and I’m thinking, how are you doing this? And in my mind is

telling me and I kept asking all along during this process, when do I get to

advanced eating more? I want to eat more and they said you don’t get to

advance. Well, I have advanced so that’s why I keep thinking I’ve

stretched my stomach. It’s not the thing of being hungry, it’s nothing, it’s

a mental thing that you want to eat more. So I’m still trying to learn that.

I’m still trying to get through that part of it. But when you start feeling like

you put a couple of pounds on or something like this, I mean when you

can feel it you also know to cut down again but you want to eat more. It’s

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a different mindset. – Luke, 61, white, retired small business owner, 1 year

post-surgery

For most patients, in the period immediately following surgery they have no appetite.

Many report having to force themselves to eat—but Luke reported not having this loss of appetite. For Luke, his appetite continued to say “yes” to foods while his modified stomach gave an emphatic “no.” But now that he is healing, he worries that he pushed his stomach too far.

The self-blame involved with weight gain after bariatric surgery dominates many other explanations for weight gain—including the possibility of critique of the procedure and bariatric program (Boero 2012). Dilation of a patient’s modified stomach pouch can occur through stretching with overeating, but it also occurs as a natural part of the healing process after surgery (Flanagan 1996). Despite this, when patients talk about weight gain and pouch stretching, they most commonly attribute it to bad patient behavior.

But to take a pouch that they have taken from football size down to the size of

banana and you stretch that back out. You are really doing some things which

you shouldn’t be doing. But along with that too, if you are eating too fast, if

you are putting in too much, you are going to be sick. I don’t like to be sick. –

Kari, age 46, woman, Black, insurance claims adjuster, 5 months post-surgery

Like Kari, patients who continue to experience bariatric symptoms find it hard to imagine eating enough to stretch the pouch out. But within this is this idea that people self- sabotage their pouch by “doing things they shouldn’t do”—specifically, eating too much.

Joanne expressed a similar sentiment when I asked her if she ever worried about gaining back the weight.

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I just can’t imagine gaining it all back. It almost seems like it will be

physically impossible… you really have to work hard on that. I really

think you’d have to work hard on that. – Joanne, age 56, woman, white,

accountant, 4 years post-surgery

The implication is that people who gain back the weight work hard to do things that don’t

“follow the program.” Behind all this blame that patients place on others who gain weight, there seems to be an anxiety—it seems like a way of managing their status in the remission society (Frank 2013). If patients are unsuccessful in maintaining their weight loss, to say they “must have worked hard” to gain that weight back constructs weight gain as a moral failure. Patients who are successful can position themselves as having higher moral character—they can cast themselves as having what it takes to follow the program and therefore not being at risk of sliding back into an obese embodied identity.

Bariatric Symptoms as Worth it in the End

Underlying these beliefs about adapting, healing, and discipline is the narrative that all these symptoms are worth it. The vast majority of bariatric patients I interviewed said that they felt like the surgery was a good decision38. Losing weight, increasing

38 Darcy expressed some ambivalence. She is young and has had two bariatric surgeries and multiple corresponding weight losses. Because of a medical emergency and a fibromyalgia diagnosis, Darcy is nearly back where she started in terms of her weight. She expressed ambivalence because she is grateful for the people she has met on her bariatric journey, but continues to struggle with issues related to weight and eating. At the time of the interview, she was undergoing treatment at an outpatient clinic focused on binge eating disorder. Joe was unhappy with the fact that he remained diabetic, though he still enjoys the weight loss and feels like the decision may have saved his life. Luke also feels that the surgery saved his life. But he expressed that if given the choice to do it all over again, he would not. He felt that his early struggles with appetite were very difficult. Maria, Lucy, and some other patients further out expressed frustration about the lack of support for patients who are past the first few post-surgery years. But most of them feel that surgery was the right decision—even if they have some feelings of ambivalence. 132

mobility and fitness, reducing the need for medications (at least prescription drugs), and reducing the stigma of being fat all made it worth the pain of the surgery, possible complications, and bariatric symptoms. In fact, many patients reported that they wished they had undergone bariatric surgery sooner. Sally compared bariatric surgery to giving birth to a child.

Let's say you're having a baby. And it's horrible. You end up C-section.

Everything happened that could possibly happen. You go home with a

baby. Are you unhappy? No! You have a baby! Ok, you go in for

something else. You go in for your appendix and they, your bowel

ruptures and this happens and you have to have a blood transfusion. Are

you happy? No! You are unhappy! Your outcomes are colored by what

[you’re expecting]. – Sally, age 59, woman, white, respiratory therapist,

pre-surgery

To Sally, undergoing bariatric surgery is more like having a baby than having an appendectomy. Even if you have bad outcomes from the surgery, the end result—a baby or massive weight loss—outweighs the possible complications that come with surgery.

It’s not just patients but practitioners and payers who have come to the conclusion that the risks associated with bariatric surgery are worth undertaking for the benefits.

Private insurance as well as public programs (Medicare and Medicaid) are increasingly covering bariatric surgery under the assumption that losing weight through surgery will

Patients are much more likely to blame themselves than the surgery for their later struggles to maintain their weight loss. 133

ultimately limit the risks associated with obesity. Nichole, herself a physician, discusses this cost-benefit thinking when it comes to bariatric surgery.

Well, I hate to invite morbidity… I don’t want to change my anatomy. I

don’t want to take myself potentially and have illnesses and have

problems with an elective surgeon or elective surgery. I’m inviting

potential health issues and concerns that I didn’t have before. But if I do

nothing, and I keep doing what I am doing, I very likely will have diabetes

and probably I would have, my risk of cancer would be higher. I would

have problems if I do more thing also. So that’s makes it really hard I

think. – Nichole, 44, white, medical doctor, pre-surgery

But in the end, she decided that the surgery was worth it to optimize her health to avoid the illnesses associated with obesity.

Among patients who had bad outcomes after surgery—serious complications or weight gain—most of them told me that the surgery was still worth it. When Erma’s son talked her into bariatric surgery, Erma was very sick and facing the possibility of living the rest of her life in a wheelchair.

I couldn't hardly walk. I was 351 pounds, so I couldn't hardly walk. And

I'd almost have to sit down or need a wheelchair. I… it was… I was either

going to die or end up in a wheelchair or have bariatric surgery. That was

my choices. So I went into bariatric surgery… even when I was going,

they were putting me to sleep. I thought, "If I die, I die. I got to do this." –

Erma, 75, white, retired realtor, 6 years post-surgery

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After her surgery, Erma contracted an infection. She nearly did die39 and it took her a year to fully recover.

I almost died too. I had an infection. And they had to go in and operate on

me. And then I had to wear a bag, there's a picture of it in here. It was in

my stomach and it was like a purse and it was sucking the infection out.

And nurses came to the house. It was… I lay in bed a couple times and

through, come on and I just should die. Because I'm tired of all this. You

know? But right now, if I had to do it over, I would. – Erma, 75, white,

retired realtor, 6 years post-surgery

Even though Erma suffered greatly from her infection and she has struggled to maintain her weight loss—even gaining a substantial amount of weight after surgery—she still does not regret her choice to undergo surgery. For Erma, she felt that death was a better option than the way she was living before surgery.

Maggie expressed a great deal of dissatisfaction more than ten years out from her surgery. She repeatedly asserted that she felt as though she had never had the surgery in the first place—her bariatric symptoms were almost completely gone. As a result of losing symptoms and losing contact with the clinic, she gained 40 pounds and now she was struggling again with the obese embodied identity—feeling that her body was out of control and trying to lose weight using conventional diet and exercise. I asked Maggie,

39 After Erma had recovered, she was featured in the bariatric fashion show. Her son tearfully confessed to her after the show that he had blamed himself when she nearly died for his role in convincing her to undergo surgery. He expressed tears of joy when he saw her literally paraded out as a clinic success story. 135

“What advice would you give someone who was considering undergoing bariatric surgery?” She said, “Do it.”

If you become one of those people then you’ve increased your life, you are

living a life where when people are obese or it’s just so heavy, it’s like I’m

living life now even though I’m heavy but a lot of people are so heavy they

can’t live life. They need to have the surgery so they can have a little taste of

what living is and then hopefully they’ll stick with, even if they gain weight

like I did at least they’ll be, fat is fat but at least it’s healthy. It’s salads and

it’s lots of fish, stuff like that. So yeah, I would say definitely do the surgery.

Yeah, you got to do it, you got to learn how to live life and maybe end up like

Pete where he is, just amazing. – Maggie, age 49, woman, white, small

business owner, 11 years post-surgery

Maggie gives two reasons why she thinks bariatric surgery is worth it despite her weight gain. First, she believes that it’s possible for fat people to lose a substantial amount of weight and keep it off (through diet, exercise, and/or surgery). She references Pete, another bariatric patient who she refers to as “her hero.” Pete has become a poster child for the bariatric clinic, going from a big guy having a heart attack to a 60-year-old athlete.

Second, Maggie feels that bariatric surgery is worth it—even if it doesn’t result in long- term weight loss—just for the experience of living in a body that is free from the limits of obesity.

You get a taste of that lifestyle of seatbelts and [amusement park] rides

and airplane, you know what I mean, and it’s like you get a taste of that

and once you get a taste of that then you seem like you always crave it, but

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food kind of takes control again. – Maggie, 49, white, small business

owner

Almost all patients regardless of complications or weight gain said that if given the choice they would do it over again. It is worth it if only for a taste of a life free from the stigma of a fat body.

Conclusion

Bariatric patients commonly compared the illness experience of obesity to being trapped by their fat bodies. One way they view their obese embodied identities as illness is through experiencing limited mobility from pain and lack of fitness. Obesity stigma is in many ways a health-related stigma. Obesity is not only constructed as illness, but also obesity and chronic illnesses related to obesity are constructed as the fault of the fat individual and their immoral, unhealthy behaviors (Boero 2012; Kwan and Graves 2013;

Metzl and Kirkland 2010; Saguy 2013). Fit embodied identities in contrast are constructed as morally superior—they are applauded for their apparent self-discipline in optimizing their health (Crawford 1980; Metzl and Kirkland 2010). Therefore, it’s not surprising that many patients before and after surgery strive to shed their obese embodied identity in favor of the morally superior fit embodied identity. However, patients face significant social barriers to this transition—especially before surgery. For one thing, being seen struggling with low fitness while fat carries an extra burden of shame and embarrassment. For another thing, the built environment around fitness is rarely accommodating to large bodies.

For many patients, mobility is more a matter of pain—especially when heavy bodies combine with injury, aging, and disability. For some patients, their mobility issues

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are so severe that they feel they have no choice but to undergo bariatric surgery. Some expressed that their life was so impaired by their pain and mobility issues that it was not worth living. For patients with such low levels of mobility, their bodies felt especially like prisons which prevented them from fully engaging in day-to-day life. These issues were exacerbated again by a built environment which does not accommodate difference in terms of size and (dis)ability.

Medical treatment—especially prescription medication—is an important way that patients mark transitions between illness and health. Patients commonly expressed a desire to be “free from medication.” Freedom from medication is freedom from the cost of medicine as well as freedom from the troubling side effects of medication. But, most importantly, freedom from medication is an important symbolic marker of freedom from chronic illnesses that those medications represent. Patients count down the numbers of medications they are taking as a way of accounting for their transition from an obese embodied identity to a more healthy bariatric embodied identity. Likewise, they count down the number of opioid painkillers they take as an indicator of their healing process after surgery.

At the same time that patients are losing prescription medications and other medical treatments for chronic illness, they are adopting a lengthy and complicated regimen of taking vitamins and supplements. Bariatric patients often must supplement their diets after surgery in order to account for the malabsorption in their digestive system. As a result, patients are not free of the surveillance, rituals, and dependence on medicalized control. But supplements and vitamins do not carry the symbolic weight of illness that is carried by prescription medication. In our society, the social construction of

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health and illness is often fraught with discourses about health behavior. Each individual is responsible for their own health and illness, and those who are fat and sick have only their immoral, slothful, gluttonous behaviors to blame. Behaviors which optimize health, on the other hand, are seen as evidence of superior moral character—of self-discipline and restraint (Metzl and Kirkland 2010). When patients long for freedom from medication, what they really long for is freedom from the stigma of chronic illness and obesity.

Once patients have undergone bariatric surgery, they experience various bariatric symptoms. These symptoms would be considered signs of illness in an unmodified digestive system. For bariatric patients, however, these uncomfortable, painful, and even embarrassing effects of the surgery are not viewed as illness. In fact, bariatric patients experience their bodies as healthier than their previous, unaltered bodies. Instead, these symptoms are normalized. They are read as a normal part of the healing process or seen as something to adjust patients’ lifestyles to accommodate. This is because, fundamentally, these bariatric symptoms are a key part of the weight loss through bariatric surgery. They are the thing that differentiates bariatric surgery from traditional dieting. In traditional dieting someone can “cheat” with few consequences other than weight gain. After bariatric surgery, eating too much too fast causes intense pain and discomfort. Eating too much sugar or fats or carbs causes “dumping” which can be embarrassing as well as uncomfortable. When these symptoms begin to fade, often bariatric patients don’t celebrate this as a sign of healing, they fear it as the decline of their initial, rapid weight loss. In the end, bariatric patients—even those who regain or

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deal with serious complications—view their symptoms as worth it if only for a taste of a life free from the burden of fat stigma.

What bariatric accounts of illness and sickness demonstrate is that the symptoms and signs of illness are not objectively meaningful. Instead, the meaning granted to these experiences is filtered through the symbolic meaning carried by obesity, chronic illness, and biomedical interventions. Experiences of health and illness are filtered through the moral framework of healthism and biomedicine, which frames health and illness as an individual moral responsibility (Clark et al. 2010; Crawford 1980; Metzl and Kirkland

2010). Limited mobility is meaningful when it prevents a patient from participating in daily productive activities. Limited fitness carries the moral stigma of healthism, where bodies which can move athletically are given moral superiority over bodies which are aging and disabled. The shame patients feel is intensified by the built environment, which is built for more privileged young, able-bodied, and thin bodies. Medications that treat chronic illness or acute pain carry the moral burden of those illnesses, where vitamins and supplements are a sign of morally superior, health-optimizing behavior (Conrad

1985; Metzl and Kirkland 2010). Bariatric symptoms are not constructed as illness but tools to promote weight loss. The pain and embarrassment of losing your meals or lying on the couch hoping the pain will pass soon is all worth it in the end to achieve a healthy and morally superior thin body.

These findings provide insight into how bariatric patients construct their embodied experiences and how these constructions are shaped by fat stigma, health morality, and the medicalization of obesity. Obesity is a condition that exists between a highly medicalized discourse and a highly moralized discourse about health behaviors.

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This social context fundamentally shapes how bariatric patients experience their embodiment both before and after surgery. The lenses of health morality and fat stigma filter bariatric patient experience and shape the ways in which they account for their embodied symptoms. This not only has implications for how we understand bariatric surgery but also the experience of other biomedicalized bodies. Advances in biomedical technology mean that instead of medicine primarily focusing on repairing or restoring the body, biomedical technologies are increasingly being used to optimize and modify the body. This study provides insights into how other biomedicalized embodied subjects make sense of these changes to their embodiment and construct their experiences of health and illness.

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CHAPTER V

SKIN DEEP

APPEARANCE, HEALTH, AND STIGMA

One aspect of embodiment that is particularly laden with symbolic meaning is appearance. In Western culture, fat bodies are stigmatized, in part because they are outside of the prescribed norms for health and appearance (Kwan and Graves 2013;

Lebesco 2010; Saguy 2013). In this chapter, I will explore the relationship between appearance, health, and stigma as they emerge in the accounts of bariatric surgery patients. I will also discuss the intersections between embodied appearance and race, gender, and age.

Pauline, a 1-year post-surgery bariatric patient, has an intimate understanding of this stigma not only because of her status as a formerly obese embodied person, but also because of her concern as a mother for her obese embodied daughter. Pauline is a middle- aged woman appearing to be of normative weight and slightly taller than average height.

When we met in her modest but cozy single-story home, she wore no makeup and her hair was dyed red with grey roots showing. Polly—Pauline’s 26-year-old daughter—was lounging on a large chaise recliner watching the Disney Channel. Polly was a very large woman wearing capri-length pants and a t-shirt printed with children’s cartoon characters. Her hair was the same dark red shade as her mother’s. Polly has autism and lives under her mother’s full-time care. Beneath her glasses, she narrowed her eyes and shouted a series of questions and declaratives at me. “You Corey Steven?!” I told her I

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was. She exclaimed “Corey Steven!” when she had a question for me, giving me that same narrow-eyed, skeptical look.

I had Pauline sign the consent form and then offered one to Polly. Pauline guided

Polly through signing the consent form, which she did with shaky, child-like handwriting.

Early in the interview, I would try to ask Polly questions, which Pauline had to carefully relay to her. After a few of these exchanges, Pauline told me that it would be better not to ask her any more questions. Pauline didn’t want Polly to go on and on and disrupt the interview. It was clear that verbal communication was difficult for Polly. Polly sat and watched the Disney Channel during our interview, occasionally inserting questions to me—mostly about my cats. She did issue a few statements about bariatric surgery.

Polly: I'm surgery sick.

Pauline: I know you want to have surgery.

Polly: I can't swim.

Pauline: After surgery, no, you can't swim right away.

Polly: I'm stay home.

Pauline: Ok.

Polly also informed me that I was not to touch her stomach. I assured her (multiple times) that I would not touch her. I wondered if she associated discussing bariatric surgery with invasive prodding of her body.

Pauline demonstrated calm and patience when addressing Polly. A former nurse,

Pauline left her job after Polly completed high school. She was having trouble finding caretakers who could manage Polly’s temper. “You have to find someone who at least pretends to like the person while they're working.” Her husband supported the family

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through his military career. Pauline confessed that, like many full-time caretakers, she struggled with depression—managed mostly through medication—though she was feeling less depressed and more confident because of her recent weight loss.

Pauline underwent bariatric surgery at the clinic. When she asked her surgeon if he would perform the surgery on Polly, he refused because of the consent issues involved in operating on a person with autism. Pauline then went to a more prestigious hospital system in a larger, nearby city. Polly’s case was under review by the hospital ethics board at the time of the interview. In the meantime, a doctor at the large hospital had Polly on a low-carb, high-protein diet. Pauline was skeptical that the diet would work based on previous experiences with similar diets.

They call it a “modified protein sparing fast” and basically it's the starter

Adkins which, I mean, we've tried Adkins and yeah, you can lose a lot of

weight on that diet, but the minute you start eating regularly, it just pops

back on.

While the ethics board at the hospital debated the consent issue with Polly’s surgery, Pauline began talking with surgeons in Mexico who would perform the surgery.

She had found a few that were willing—though she would prefer to put Polly through a more comprehensive program in the United States. Pauline believes that bariatric surgery is the right decision for her daughter. Like all prospective bariatric patients, Polly had been on so many diets, exercise programs, and medications, and none of it had worked long term. Pauline was concerned about her daughter’s health; Polly had recently been diagnosed with diabetes. In addition to her health, Pauline was also concerned about

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Polly’s weight because her size, like her neurological difference, made her a social outsider.

It's the only thing that's going to let her move around and be happy in her

body for whatever time she has left on this earth, you know? It's difficult

to be made fun of, to not have any friends, and I think most heavy people

probably feel that way. That people look at you or laugh at you behind

your back or whatever, and she's not with it all the time but… she has

autism, and even if she does act like she's not paying attention, she'll bring

it up later on. So she hears and she comprehends. It just takes her a while

to spit it back out.

For Pauline, Polly’s size and the social stigma it carried was a quality of life issue. When

Pauline reflected on her meeting with the hospital ethics board, she regretted not presenting her concerns about Polly’s social well-being in stronger terms. She compared

Polly’s body size to the issue of a young child with a cleft palate—a facial disfigurement.

I understand to some extent that because Polly is autistic, they have some

assent/consent issues. But I kind of liken it to a kid that's got a cleft palate.

That doesn't give him a problem with eating, drinking, breathing. It's just

going to be a physical deformity that's going to bother him as he grows.

Will they do that surgery? [sic] It's not an emergency! It's elective! It's

elective. [sic] But it's going to affect that child as he grows. Other kids are

going make fun of him, you know. I mean, obviously there are other issues

other than somebody making fun of Polly. There's cardiac disease,

diabetes, all kinds of problems for her. But if they can give a two-year-old

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that type of surgery, they certainly can't assent to it. It’s still an elective

surgery. This is just how I'm looking at it. It's simply for the child and the

parents’ peace of mind so that the child doesn't go through life with a

“don't look at me” kind of thing. I don't see a difference, you know, if you

can give consent for a two-year-old for an elective surgery like that, why

can't I give consent for [Polly]? I'm her guardian. Why can't I give

consent for her?

Pauline believed that, for her daughter, the benefits of bariatric surgery far outweighed the risks. A cleft palate in a child is considered a social emergency (Talley 2014). From

Pauline’s perspective, Polly’s size is just as disfiguring and socially crippling as a facial deformity.

For bariatric patients like Pauline and Polly, appearance is more than just skin deep. Their bodies carry a visible stigma which marks them as an unhealthy other, an unsightly burden on society. The experiences of bariatric patients like Pauline and Polly shed light on the complex relationships between appearance, health, and stigma. In accounting for their embodied experience, bariatric patients recount their struggle to shed both the weight and the visible stigma of obesity.

Obesity, Stigma, and Health

In Stigma, Goffman (1963) defines stigma as “an attribute which is deeply discrediting” (p. 4). Goffman illustrates three types of stigma: “abomination of the body,” such as visible disability and disfigurement; “blemishes of individual character,” such as those labeled criminals or addicts; and “tribal stigma” passed down from generation to generation, such as stigma against different racial and ethnic minorities (p. 4). Fatness is

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considered as “abomination of the body” in dominant Western culture, in which fat bodies are considered ugly (Lupton 1996; Farrell 2011; Kwan and Graves 2013; Saguy

2013). However, fat bodies are also believed to indicate “blemishes of individual character,” such as greed, gluttony, laziness, etc.40 Body fat is widely believed to be under the control of the individual, and those who fail to control their weight are considered moral failures (Bordo 1993; Jutel 2005; Kwan and Graves 2013; Lupton 2013; Saguy

2013).

Goffman (1963) further differentiates between discredited identities (people with known stigma) and discreditable identities (people with hidden stigma). Fat bodies are always visible—especially those who are large enough to qualify for bariatric surgery.

Fat people cannot hide their stigmatized bodies—no matter what they wear. As a consequence, their identities are perpetually discredited (Saguy 2013; Saguy and Ward

2011). Jeannine Gailey (2014) argues that the visibility of fat bodies has a paradoxical effect that she terms “hyper(in)visibility.” While fat bodies are hyper-visible—both in terms of their physical presence and in the discourses about the obesity epidemic—fat embodied individuals are marginalized. Their voices are not heard in the discourse about obesity and they often feel invisible in their day-to-day lives. While fat people remain hyper(in)visible in discourses about obesity, fat stigma has real consequences for fat people’s life chances. Fat people experience discrimination in almost all aspects of their lives, including employment, education, health care, and interpersonal relationships

(Fikkan and Rothblum 2012; Puhl and Heuer 2009; Puhl and Brownell 2001).

40Some fat studies scholars also argue that fat stigma can be considered a tribal stigma (Farrell 2011; Lupton 2013) because of the strong role genetics plays in body weight (Bacon and Aphramor 2011; Mann 2015). 147

Discourses about health are important in the construction of fat stigma. Medicine has become a major source of social control through the increasing medicalization of society (Conrad 1992; Zola 1972). Given the strong influence of neo-liberalism in

American culture, individuals are believed to be responsible for their own health outcomes. In this context, if someone is unhealthy, they only have to look at their own behavior and lifestyle for the source (Crawford 1980; Kwan and Graves 2013; Metzl and

Kirkland 2010). The impetus to adopt healthy lifestyles has taken on increased moral meaning since the 1970s—especially among the middle class (Crawford 1980; Kwan and

Graves 2013). This medicalization of everyday life is only expanding with the increased development of biomedical technology and interventions—such as bariatric surgery. This biomedicalization allows the gaze of medicine to extend deeper and deeper into the everyday lives of individuals, spreading with it the moral impetus to optimize one’s health (Boero 2010; Clark et al. 2010; Conrad 2005).

Obesity has become synonymous with health crisis in contemporary Western society. Dominant narratives about the obesity epidemic assert that our expanding waist lines are causing preventable death and illness, putting children at risk, and costing taxpayers millions in medical costs (Kwan and Graves 2013; Lupton 2013; Saguy 2013).

As the moral panic surrounding obesity has risen (Lebesco 2010), so too has the discrimination fat people experience (Andreyeva et al. 2008).

Fat patients are labeled unhealthy automatically because of their body size (Jutel

2005; Jutel and Buetow 2007), despite mounting evidence that people labeled

“overweight” and “obese” can be—and often are—healthy (Bacon and Aphramor 2011;

Mann 2015). Annmarie Jutel (2005) argues that in Western culture there exists an

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“aesthetics of health” where a healthy appearance conveys a moral fortitude, a willingness to engage in self-improvement. When health is seen as a moral virtue based on hard work and avoiding “bad food” (Lupton 1996), individuals who cannot meet the standards of health are constructed as “unhealthy others” (Crawford 1994; Kwan and

Graves 2013). Fat people carry this status as moral failures on their visibly fat bodies— bodies which are constructed as inherently unhealthy due to lack of willpower (Boero

2012a; Jutel 2005; Kwan and Graves 2013; Lupton 2013; Saguy 2013).

Many people seek to manage the stigma of obesity through dieting and weight loss. In the United States, over 100 million people diet—fueling a 20-billion-dollar industry (ABC News Staff 2012). Goffman (1963) notes that stigmatized people may seek to correct their stigma and repair their identity. However, “where such repair is possible what often results is not the acquisition of fully normal status, but a transformation into someone with a record of having corrected a particular blemish” (p.

9). Instead of carrying the privileged identity of “thin” or even “normal,” the formerly fat often continue to carry the stigma of being formerly fat (Carr and Jaffe 2012; Fee and

Nusbaumer 2012; Granberg 2011; Mattingly et al. 2009; Blaine, DiBlasi, and Connor

2002). Can fat people ever fully exit the stigma of obesity? Research on people who have lost significant amounts of weight yields mixed results.

In order for a fat person to exit the fat stigma, she must first lose weight. Then she must accept herself as a thin person—or at least not a fat person. Others must also accept her as a normal-sized person as well (Granberg 2011). Qualitative (and mixed method) research has shown that some people do achieve stigma exit—often after years of successfully living as a thin person (Carr and Jaffe 2012; Granberg 2011). But there are a

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number of barriers to full stigma exit. For many, the difficulty lies in getting others to accept them as a “normal” person—for instance, giving a person compliments on their weight loss actually hinders full stigma exit by identifying a person as formerly fat

(Granberg 2011). Studies consistently find that people continue to hold stigmatizing beliefs about formerly fat people (Blaine et al. 2002; Fee and Nusbaumer 2012; Mattingly et al. 2009). People hold especially stigmatizing views of bariatric patients, who they believe have “cheated” or “taken the easy way out” (Drew 2011; Mattingly et al. 2009).

There are a number of biological, psychological, environmental, and social barriers to losing weight in the first place. In fact, weight loss is rarely successful in the long term—only about 5% of dieters successfully lose significant amounts of weight and maintain that weight loss (Mann 2015). Formerly fat people who are successful at maintaining their weight loss often experience identity lag where they struggle to see themselves as thin after holding an obese identity for so long (Carr and Jaffe 2012).

Embodied aspects of a former fat identity can be an impediment to this process. For instance, some former fat people may feel disappointed by their incomplete weight loss or experience weight loss as an ongoing struggle (Carr and Jaffe 2012; Granberg 2011).

While much of the work on stigma exit for the formerly fat has focused on identity, there is only a passing mention to embodied issues of stigma exit. In this chapter, I examine how visible markers of a former fat identity prevent bariatric patients from fully exiting the stigma of obesity.

Fat Stigma and Intersectionality

Of course, no discussion of bodies is complete without acknowledging how embodied experiences are shaped by the intersections of gender, race, class, and other

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identities (Collins 2000; Glenn 1999). The social construction of fat as a social problem has been steeped in narratives about race, class, and gender from the beginning (Farrell

2011; Fraser 2009; Stearns 1997). Fat stigma has different consequences for different groups of people. While fat men do face gendered issues of fat stigma (Monaghan 2008;

Bell and McNaughton 2007; Gilman 2004), women bear the brunt of fat stigma—facing steeper consequences to their life chances for straying from prescribed feminine norms of size and beauty (Fikkan and Rothblum 2012; Hartley 2001; Bordo 1993; Bartky 1990a).

Given the pressure that women face to be thin, it’s no surprise that the vast majority of dieters (85%) and bariatric patients (81%) are women (Martin et al. 2010; ABC News

Staff 2012).

In terms of class, prior to the 20th century, fat bodies were a sign of prosperity and wealth (Fraser 2009). Due to a series of cultural shifts in the industrial era, fatness has now come to be seen as a sign of low status (Fraser 2009; Stearns 1997). On average, body weight is much higher among people of lower SES. More-privileged people with the resources necessary to secure healthy food and engage safely in regular exercise tend to be thinner than their poorer counterparts. Thin bodies have come to represent higher class status (Ernsberger 2009; Lippert 2016; Wardle, Waller, and Jarvis 2002).

Fat studies scholars have argued that not only are people of lower SES more likely to be fat, but also that fat is impoverishing (Ernsberger 2009). For instance, fat people are more likely to fall below the poverty line and less likely to be economically upwardly mobile than their thin peers (Ernsberger 2009; Gortmaker et al. 1993; Graham and Felton 2005; Wardle et al. 2002). Fat people face bias and discrimination in

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education and in the workplace (Ernsberger 2009; Puhl and Brownell 2001; Puhl and

Heuer 2009). This is especially true for fat women (Fikkan and Rothblum 2012).

In the early 1900s, immigrants from other cultures were immigrating to America in droves. These groups became associated with fat embodiment, and thin embodied ideals developed to separate privileged white groups from these immigrants (Farrell

2011). Indeed, non-white people continue to have higher body masses (as well as higher incidents of chronic disease) due to the class issues highlighted above in addition to the disadvantages of racism (Bacon and Aphramor 2011; Williams 2012). The thin body has come to be an important way in which white, class-privileged embodiment is constructed in our society (Farrell 2011).

Some racial and ethnic subcultures in the Western world resist fat stigma and

Westernized beauty standards (Fikkan and Rothblum 2012; Brewis et al. 2011; Graham and Felton 2005). For instance, there is some evidence that African Americans may be protected from fat stigma through alternative notions of beauty, size, and health—though results are mixed (Fikkan and Rothblum 2012; Roberts et al. 2006; Perez and Joiner

2003; DiGioacchino, Sargent, and Topping 2001; Lovejoy 2001). However, some scholars have criticized the idea that Black women are protected by African-American beauty standards, arguing that these ideas obscure real health and body image issues in the Black community (Fikkan and Rothblum 2012; Beauboeuf-Lafontant 2003; Perez and

Joiner 2003; Lovejoy 2001). Furthermore, there is evidence that advancing one’s class comes with increased pressure to conform to dominant, white beauty standards— including pressure to be thin (Roberts et al. 2006; Lovejoy 2001).

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Bariatric patients experience visible fat stigma in complex ways. Throughout this chapter, I describe how patients’ experiences are shaped by race, class, gender, and age.

First, I provide examples from patients’ accounts of how visible fat stigma impacts their lives and leads them to choose bariatric surgery. Next, I examine the complex relationships between appearance, health, and visible stigma. Bariatric patients construct a moral dichotomy between appearance concerns and health concerns—viewing the former as “the wrong reason” to undergo bariatric surgery. However, there is a distinct aesthetic of health in how patients describe their bodies. Finally, I discuss how patients’ attempts to exit the stigma of obesity are often incomplete—in part because of the visible markers of obesity on the body.

Findings

“There is No Holding You Back”

For fat people—especially fat women—visible fat stigma carries real consequences in terms of discrimination and status loss (Fikkan and Rothblum 2012;

Puhl and Heuer 2009; Link and Phelan 2001; Puhl and Brownell 2001). Given these pressures, fat people’s concerns about appearance are far from superficial. In Natalie

Boero's (2012) ethnographic exploration of bariatric surgery, she concluded that bariatric patients are not seeking to reach a thin ideal; instead they are seeking a “normal” body.

Most bariatric patients I spoke to replicated this finding. In seeking to drastically change their appearance by losing large amounts of weight, bariatric patients are not always pursuing idealized beauty. Instead, they are seeking to exit the fat stigma that plagues their lived experiences and limits their life chances.

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Patients are keenly aware of stigmatizing attitudes about fat people. Jane was diagnosed with brain cancer and had to undergo brain surgery to save her life. She recovered, but the doctor placed her on steroids which drastically increased her weight.

This rapid weight gain has given her a unique insight into the impact of fat stigma on status.

I don’t fat shame people. I never have been that way. But it’s just now that

I have experienced being this big, it’s horrible. I think the society views

people that they are greasy and they are nasty and they are lazy and all

that. That’s not the case. I mean, people gain 5 or 10 pounds a year and

before they know it, in 10 years, you gain 10 pounds a year, you are 100

pounds overweight. It just clicks up on you. I don’t think the majority of

people that I know that are obese or considered morbidly obese hardly eat

at all and they are not lazy people. If anything, they are really not. They

are highly functioning. So I guess it makes me a little bit angry [at the

word obesity]. But I do understand that it’s an issue in our society,

especially in America, my goodness. – Jane, 44, white, disabled

When people look at fat people, they make assumptions about their behavior—i.e., they eat a lot and are lazy. To Jane, this cultural perception is unfair to herself and other fat people that she knows.

While Jane gained her weight rapidly, most bariatric patients struggle with fat stigma from a young age. Many patients experience fat stigma in childhood.

I try to think back, when did all this start? And when did I start, like,

gaining and, you know, I've always been, I've always felt like I've been

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heavy. But, you know, I got teased a lot in school, you know. Didn't help

my last name was [a food item]. I had a unibrow, you know, so I had a lot

going against me from other aspects, and I think all of that just kind of

doesn’t help the whole weight thing in and of itself. – Gabby, 50, white,

retail worker

These early experiences of weight-based bullying can have a lasting impact on people’s well-being (Weinstock and Krehbiel 2009). Being picked on for her weight and appearance as a child left Gabby with a deep sense of body shame and low self-esteem which continued into her adult life—even after her surgery.

Patients continue to experience stigma in their day-to-day interactions with people—although perhaps in subtler, more “polite” ways (Stevens 2017). Harriett describes the difference in how her colleagues in the medical profession treated her after losing weight.

I’m a lot more confident. People treat me better. I didn’t realize the

amount, you hear that fat bias. I didn’t realize, like, people that I had

known for years that never would look me in the eye, never spoke to me,

and now they speak to me… maybe it’s I’m more open to a conversation,

but yeah, there’s definitely a different type of interaction. – Harriett, 57,

white, nurse

Harriett and many other women in this study describe a phenomenon where their visible fat stigma renders them invisible to others. In her study of women’s experience of fat stigma, Jeannine Gailey (2014) termed this phenomenon “hyper(in)visibility”—while obesity and fatness are hyper-visible in society, fat women are marginalized and

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invisible. Many bariatric patients discussed how people—especially men—were more friendly and willing to engage them in conversation once they had lost weight.

Two women discussed how this hyper(in)visibility was useful in some ways to keep undesirable men away. Nichole described her fat as making her “invisible” and her surgery as an attempt to stop hiding from others.

Corey: So do you think being fat helps you be invisible?

Nichole: To men, sure. Or just say with the interactions that I have had

with men or exchanges I had. It’s collegial, it’s professional. I know it has

nothing to do with ulterior motives or attraction anywhere. When I was

attractive and I would be frustrated that men would like me and not know

anything about me and just like how I looked. So I sort of flipped the

equation, but I took it too far.

So that’s something that will come out I’m sure well, and I won’t quite

know. I won’t feel a little bit like a disadvantage sometimes. Some women

feel they have a lot of power in those moments, because someone who is

attracted to them and they get to say who they are with, but I sort of feel

like destabilize by those comments and at a disadvantage in terms of

power. – Nichole, 44, white, medical doctor

Nichole felt that her fat body protected her from experiencing the objectifying gaze of men—especially male coworkers. She worried that she was going to have trouble entering back into the world of attractive or at least “normal” women who experience this gaze every day.

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Even though Nichole felt that fat allowed her to hide from the male gaze, she also saw her fat as “holding her back” from fully achieving important life course milestones.

She articulated this when she described talking to her parents about her surgery.

My mom is worried, but I think she also wants me to be happy. So it’s

hard for them to hide [that I] don’t have a partner or don’t have children or

don’t have some things in my life that I would like in my life. So parents

would want that for their kids. They want their children to be happy. So

they took it pretty well. – Nichole, 44, white, medical doctor

Other people shared Nichole’s sentiment that her fat was holding her back from achieving her personal and professional goals. One friend and colleague called her after surgery and said, “This is great. Now you’re going to be able to be who you are with no apologies. There is no holding you back.” Nichole had been so successful in terms of her education and career, yet she felt that her weight was holding her back from achieving other important life events like finding a partner and having children41.

Nichole has a great deal of success in terms of her education and her class standing. At the time of the interview, she had completed medical school and worked as a resident at the large hospital system which included the bariatric clinic. But her embodiment as a fat woman prevents her from fully accessing white, class privilege. In fact, Nichole herself notes that race plays a role in the way she feels about her body.

I’m self-conscious of my body, and definitely wanting to make it as

unintrusive as possible, I make it not an issue. Reason is, I think if I am

41 The majority of people I interviewed did have partners and children, although concern about finding a partner was common among young, single people I interviewed. 157

African American, I would carry my heavier body better. I will just have

more pride and more attitude that I don’t have. – Nichole, 44, white,

medical doctor

The ideal thin, white body is constructed in opposition to the Black body. There are cultural tropes about Black women’s fat bodies—such as the strong, large Black woman

(Beauboeuf-Lafontant 2003). Of course, many of these tropes have been critiqued as controlling images (Collins 2000) which obscure racial inequality and its impacts on

Black women’s health (Beauboeuf-Lafontant 2003). whiteness is constructed in opposition to these controlling images of immigrants and Black and brown people

(Farrell 2011), although some white people are viewed as not quite living up to these standards of whiteness—usually due to class (Wray 2006). Like so-called “hillbillies” or

“white trash,” fat people are failing to live up to the embodied standards prescribed for successful white, middle-class people.

Darcy’s story illustrates how anti-fat bias can significantly impact a person’s economic mobility. Darcy was fired from a job because her boss kept insisting that her hygiene was not up to the office standards.

I actually had a decent job half of the time and did get to fly a couple of

places. But I think the heaviness ruined my chance with that job. I was

there a year and a half, and after a while [my boss] just started to complain

about how I smelled, except nobody else was. I was at my heaviest. I

really think she had something against fat people. Like, one day she just

let me go without any warning after a year and a half… that’s the only

professional job I’ve ever had and lost it like that, and then I have never

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been able to get anything since, even though I’m not as fat as I was, but I

think people still look at you and they are like, “No.” I’ve been [out of]

grad school 8 years and you are telling me that nobody has been against

my weight? Do you know how many interviews I’ve gone through? Yeah,

somebody had, they all have something against you. – Darcy, 31, white,

home health care worker

Darcy struggled to find a job, and when she did find one, she was terminated, allegedly for poor hygiene and clothing choices. Darcy reasonably believes that these complaints were really about her body size and not her lack of professional grooming. She even went so far as to check with her doctor about her smell to see if something was medically wrong. The doctor said that not only was there nothing medically wrong with her, but the doctor did not notice an odor. This phantom odor may have had more to do with the stereotype that fat people are dirty, smelly, and unhygienic.

Darcy continues to struggle with underemployment. She works as a home health care aide, a relatively low-wage and low-status job which does not require a college degree. Darcy has a master’s degree in health education—focusing on LGBT and sexual health. She told me, “No one wants to hire a fat health educator.” Other women have also reported struggling to find a job after countless interviews. Sally described being denied promotion in favor of someone less qualified but younger, thinner, and more conventionally attractive. Incidents like Darcy being fired by a boss who insists that she smells bad can look like isolated incidents of one lone bigot. But when we consider the patterns in employment discrimination faced by fat people (Fikkan and Rothblum 2012;

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Ernsberger 2009; Puhl and Heuer 2009; Puhl and Brownell 2001), we have to acknowledge that there are more institutional factors at work.

Fat people don’t just contend with external factors like weight bias but also internalized feelings of shame and anxiety. This shame and anxiety has an impact on fat people’s ability to fully participate in public life (Stevens 2017). When I asked Joanne if there were any changes in how other people treated her now that she’d lost weight, she told me that she wasn’t sure if people treated her differently, but she did feel more confident in social interaction.

I think sometimes [when you are] heavier, you isolate yourself more, not

necessarily that people isolate you. You do it yourself and so they don’t

try and pull you out of there… but I don’t know. I think I find it easier to

talk to people. I don’t know that they wouldn’t have worried before. I

think I’m less conscious so therefore it’s easier to talk to strangers. It

easier to make eye contact or easier just to, you know. – Joanne, 56, white,

accountant

This tendency to shy away from other people or avoid certain social situations is a common theme in bariatric patients’ accounts of their pre-surgery bodies.

Feeling ashamed of one’s body and self also has potentially devastating consequences for fat people’s personal lives. Sally described how her shame over her body had contributed to a rift between herself and her husband. She tearfully described how she felt standing next to her tall, thin, more conventionally attractive husband.

Are you going ask me what kind of relationship I have with my husband?

Not as good as I would like it to be… my husband, I think he's extremely

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attractive. Now, if somebody else were to see him, they're like, "Are you

crazy?" You know, I think he's handsome. He is, to me, a cross between

Clint Eastwood and Charlie Heston. I think he's stunning… that's what I

see. He's muscular. He's slim. He's tall. 5'11" but to me he's tall… he's

slim. That's the build I like. I love that. Am I like that? No! I feel like, you

know, the nursery rhyme, Jack Sprat and his wife? I feel like he's Jack

Sprat and I'm his wife. "Jack Sprat could eat no fat. His wife could eat no

lean. And so between the both of them they licked the platter clean." He

was a stick and she was an apple and that's how I feel. It looks like there

was a famine—he went through it and I caused it. It's embarrassing for me

to be… it's embarrassing, I'm embarrassed for him. I don't want him to be

seen with me and people… who I think [he] is handsome and athletic and

younger than his age says. Then people meet me and think, “Oh, that's

your wife?” – Sally, 59, white, respiratory therapist

Sally’s husband never said anything to Sally about her weight, and her body issues were not something she felt she could discuss with her husband. She even mentioned not wanting to do the “bod pod”—a large device at the local university that measures body fat content—with her husband. She said that she would not want him to see her in spandex shorts and a tank top. Sally believed that her embodied appearance contributed to the intimacy issues in their relationship.

Because of the visible nature of fat, patients carry a discredited identity—their stigma cannot be hidden (Goffman 1963; Saguy and Ward 2011). The stigma written on fat bodies carries real consequences for fat people. They are hyper(in)visible, meaning

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that their visible fat stigma renders them invisible and marginalized (Gailey 2014). Fat stigma prevents fat people from fully engaging in public life and limits their life chances

(Stevens 2017; Puhl and Heuer 2009; Puhl and Brownell 2001). This burden is particularly heavy for women (Fikkan and Rothblum 2012; Bordo 1993; Bartky 1990).

Though women’s appearance concerns are often trivialized, the pressures to conform to thin, ideal femininity are overwhelming (Bartky 1990; Bordo 1993).

Doing it for “the Right Reasons”

Many of the bariatric patients I spoke to brought up the idea of having bariatric surgery for “the right reasons.” For some, doing it for the right reasons meant being sure that they were doing it for themselves, not to please other people. For some, it meant consulting with God through prayer and making peace with modifying the body God gave them. But for most patients, “the right reason” to get bariatric surgery is to improve and optimize their health. Meanwhile, getting bariatric surgery for cosmetic reasons—to appear thin and attractive—constitute “doing it for the wrong reasons.” In their narratives about bariatric surgery, patients construct a moral dichotomy between health and appearance in terms of their goals and rationales for undergoing surgery42.

I mean, yeah, it's going make me look better, but the basis of my having it

done is not to look better. It's for my health. It's to be able to enjoy the

next 40, 30 years of my life—whatever I have left on this earth. To be able

to actually enjoy it without being in pain every day. Because of my

weight, because of all the weight on my knees and my feet and I mean,

42 Bariatric patients are not the only ones who push this view that health is more important than appearance. The Centers for Disease Control (CDC), for instance, adopt this position in their anti-obesity advocacy (Kwan and Graves 2013). 162

yeah, the cosmetics is a plus. I'm not going to lie. You know, that's not the

reason I'm having it done. I mean, I think if it was, I'd be having it done

for the wrong reasons. I shouldn't be having it done just for that reason

(emphasis added by author). – Beverly, white, 48, bank loan specialist

Even women who were willing to admit to having appearance-related goals felt the need to qualify that health was more important. Like Beverly, patients often described cosmetic changes as “nice” or a “bonus” but not really a valid reason to undergo bariatric surgery on their own.

Given the moral imperative to be healthy in our culture (Metzl and Kirkland

2010; Jutel 2005; Crawford 1980), it is not surprising that bariatric patients view health as a moral imperative. But it does not fully explain why health and appearance are constructed at odds with one another. Two reasons for the dichotomy between health and appearance emerge in bariatric patients’ accounts: 1) resisting oppressive, gendered beauty standards, and 2) resisting the stigmatizing construction of bariatric surgery as a cosmetic procedure.

In many ways, prioritizing health is a good idea. Feminists have long criticized the oppressive power of beauty ideals—especially for women. A movement has arisen from these feminist concerns as well as the work of the fat acceptance movement; this movement is often referred to as “body positivity.” The body positivity movement resists body-related stigma and asserts that all bodies are worthy of respect no matter their size or appearance. This movement is often critical of diet culture, though there is debate

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about the role that weight loss can and should play in body-positive communities. Kim describes her involvement with a body-positive43 group on Facebook44.

I have spent a lot of time hating on my body and punishing it, and that got

me nowhere. I am done with that, and what that group did for me is I

haven’t binged in over a year. It stopped me binging because I wasn’t

restricting to the point where I felt like I needed to, or I didn’t feel like I

needed to punish my body anymore. That’s been really helpful for me too.

– Kim, 44, white, graduate student in nursing

Kim has worked hard to make peace with her body for her mental health. Like other bariatric patients, she finds herself grappling with disordered eating behaviors, and body- positive online spaces have helped her to accept—to some extent—her body as it is in the moment. During her first interview before surgery45, Kim spoke at length about trying to both accept and drastically change her body. She is engaged with this rhetoric that is critical about dieting culture but is also seeking to lose a large amount of weight. She

43 Body positivity factored into the narratives of a few young women that I spoke to— especially the three women who were undergoing treatment for binge eating disorder. These women are, however, in the minority. Most bariatric patients I spoke to, young and old, did not discuss body positivity. 44 While Kim was active in body-positive online spaces, she was still critical of the Health at Every Size and fat acceptance movements. 45 I should note that Kim held these views when I first interviewed her before her surgery. When I interviewed her a month after her surgery, she still referred to this world view, but she informed me that one of her goals was to “be hot.” It’s possible that this shift reflects her embodiment at different stages of the bariatric process—discussed in chapter 3. Before surgery, drastically changing one’s weight is a long and fruitless struggle with dieting. Immediately after surgery, patients lose a lot of weight rapidly. During this period of rapid weight loss, transforming oneself into a person who is thin and “hot” seems possible. 164

found oppressive beauty standards to be a detriment to this effort and certain dieting practices “triggering”—i.e., counting calories.

For Jodie, the tension between wanting to modify her own body and combat oppressive standards of beauty was very salient because of her granddaughter’s struggle with anorexia. Because her son had his child very young, Jodie played a large role in raising her granddaughter and they are very close.

I found these bracelets. I found this saying somewhere it called “Trust

your Journey.” [sic] I consider what I am doing like a journey. You buy

these bracelets and they gave you two in a pack. There was one for you

and one for somebody else. [sic] So when I first got my first set and I gave

[granddaughter] one. [sic] I look at her and I was like, you and I are both

on a journey. You are at one end, and I kind of laugh about it, your

journey is different than mine. But for her relationship [with food], she

had to repair that in her way. I said, my relationship with food, I can repair

it in my way. So that was good. But I wanted to make sure that when I

made my decision it didn’t affect her. I didn’t want to set her back,

because to see me restricting my food and trying to lose weight, and I

didn’t want her to do for her. But I talked to her openly about it and tried

to make sure because I just didn’t want… that would have killed me. I

didn’t want to set her back. – Jodi, 59, white, educational assistant

Jodi and Kim’s concerns about triggering disordered eating behaviors in themselves and other women they love illustrates the complex relationship women have with the standards of beauty and diet culture (Budgeon 2003). For women undergoing bariatric

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surgery, they wish to resist these standards while at the same time seeking to more closely meet these standards in terms of their own size. Focusing on health can help to resist the demands of beauty culture. While the thin ideal is impossible for most women to obtain, health outcomes often improve after bariatric surgery.

Responding to thin beauty standards isn’t the whole story. In fact, most bariatric patients I spoke with did not subscribe to the views of body positivity. These patients ascribed to the moral dichotomy between health and appearance in order to resist the stigma of bariatric surgery. Drew (2011) argues that bariatric surgery patients face a double stigma—bariatric patients are stigmatized both for having become fat and for losing weight in a way that is deemed immoral. Mainstream media portrays bariatric surgery as risky, extravagant, and “taking the easy way out.” People harbor more stigmatizing attitudes towards people who lose weight through bariatric surgery than those who lose weight through traditional diet and exercise alone (Mattingly et al. 2009).

Another important dimension of bariatric surgery stigma is that it is often considered a cosmetic procedure. Undergoing major surgery—which fundamentally reconfigures an important system in your body—for cosmetic purposes is considered extravagant and risky for vain reasons. But constructing it as a health-promoting—even lifesaving—procedure helps to manage the stigma of bariatric surgery. Rosie feels this stigma acutely. She told me that she was careful who she told about her bariatric surgery:

“When it comes to this type of thing, I think people think that it’s almost optional or cosmetic and there is a stigma with it.” Her family did not support her decision to undergo bariatric surgery initially. Rosie took her family in to see the surgeon to alleviate their concerns about her surgery.

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[The surgeon] was like, “Well, this is not a permanent solution; she has

got to have to make choices. This is not so she can get in a bikini next

summer. This is to save her life, this is to take the sleep apnea out of the

picture and the high cholesterol down.” He is like, “There are health

reasons for doing this.” He is like, “I’m not doing this to get people in

bikinis and have them show up on swim suit model magazine,” and I think

once they were able to actually talk to the doctor it made them feel better.

– Rosie, 38, white, customer service and sales

The conversation with the doctor helped to alleviate her family’s concerns. By reframing the issue as a health issue, she convinced her family that bariatric surgery was more important than a frivolous cosmetic procedure. The medical authority carried by the surgeon gave further weight to Rosie’s efforts to reframe her surgery as a health intervention.

The stigma associated with bariatric surgery as a cosmetic procedure has institutional implications. As concerns about epidemic obesity rise in this country, more and more insurance providers are covering bariatric surgery (Buchwald and Oien 2013).

Still, many providers do not cover the surgery because they consider it a cosmetic procedure. The first time Bob attempted to undergo bariatric surgery, he got through much of the pre-surgery process before his insurance declined to pay for his surgery.

Therefore, he was removed from the bariatric program46 unless he could pay out of pocket.

46 This was the same bariatric program where Pauline was trying to get Polly admitted as a bariatric patient—a prestigious clinic in a larger city nearby. 167

They told me to begin with when I started this my insurance would pay for

it. But then during that two years, our business had to switch insurance

companies and nothing was ever said. Well, they called it a cosmetic

surgery. Now, I could have fought it, because I had so much wrong with

me. I was diabetic. I was overweight. Not obese47—overweight. – Bob, 67,

white, retired machine shop owner

Bob’s efforts to get bariatric surgery were totally thwarted until an emergency surgery brought him into contact with Dr. D, the head bariatric surgeon for the clinic, who also works a general surgery rotation for the hospital. Dr. D encouraged Bob to start the process again at the clinic.

The reputation of bariatric surgery as a cosmetic surgery contributes to the stigma patients experience. Also, as I mentioned in the previous chapter, most patients really are concerned about their health and mobility. However, despite some bariatric patients’ insistence that health is the only moral reason to obtain bariatric surgery, appearance is a very important part of almost all patients’ narratives about their bariatric careers. To understand this more fully, we need to take a closer look at the connections between appearance and health in the experience of fat stigma.

“I Look so Unhealthy”

An aesthetic of health emerges in bariatric patient accounts of their bodies. When

I asked Sally to tell me about herself, she immediately identified herself as a health care worker who cared deeply about her own health.

47 Bob doesn’t use the word “obese” to describe himself because he views it as a slur. At over 400 pounds, Bob’s pre-surgery weight would be labeled Obese III (the largest designation) according to the medical standard (i.e., BMI). 168

I'm a respiratory therapist and that does kind of define myself in some

ways. I'm interested in medical things and that's what I do on a day-to-day

basis. So health is important to me. Yet (gestures to her body)… yet I'm

not as healthy as I could be. So that's something really important to me. –

Sally, 59, white, respiratory therapist

Sally conveys her status as an unhealthy person by simply gesturing to her fat body. Sally believes that her body is a threat to her identity as a health-conscious health care worker.

Even though the clinic operates as a medical institution, it still plays a role in promoting the connection between health and appearance. The clinic regularly puts on a

“fashion show” where patients who have successfully lost weight can show off their new bodies and wardrobes. This show is often done in conjunction with the information seminar on bariatric surgery to recruit new patients to the clinic.

Photographs play an important role in patients’ transitions. Clinic staff and other bariatric patients encourage patients to take photos regularly throughout the early stages of their bariatric careers. The clinic even provides posters where they take photos of patients at each of their post-surgery check-ups to document their progress. The way that patients discuss these photos—especially photos of themselves pre-surgery—illustrate the strong connections between health and appearance. For instance, Diana—55, Black, hospital custodian—scrolled through her phone, showing me pictures of herself before her surgery.

Diana: Oh my gosh. Oh, here's me. This is my beginning. Oh my gosh.

That's me.

Corey: Your beginner photo?

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Diana: That's the first one that they took at [the clinic]. Look! (Gasps) I

was like…

Corey: You look totally different now.

Diana: Look how, I'm just, oh my God, I look so unhealthy. Just oh! Look

at that face. It's such a pie face. It was just about 3 or 4 chins.

Patients commonly described their bodies pre-surgery as “looking unhealthy.” For Joe, an image of himself with his grandson was the catalyst for his decision to undergo bariatric surgery.

I will tell you what’s funny is what really, really made me start thinking

about [bariatric surgery] was I got, he would be 13 [year old] grandson a

couple of years ago. I was at a restaurant meeting with him. That’s when I

was at the highest weight. I was sitting in this chair, he came over and he

just put his arm around me and just put his head on my shoulder and his

mom took a picture.

When she sent me that picture, I thought I look the worst I had ever looked

in my life. I looked miserable. I looked fat. I looked depressed. That

picture, it just burned in my memory that I was never going to look that

way again. I was going to do something. I tried a few simple diets. I tried

to come back, and that just didn’t really. So that’s when I asked my

doctor. Oh yeah, she was that’s, you know, if you can do it, that’s the

thing to do. – Joe, 64, white, retired dairy plant supervisor

Joe believes that this picture saved his life by pushing him to do something about losing weight—he even told his grandson as much on Facebook. To Joe, he looked mentally ill

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in that photo, looking “miserable” and “depressed.” Fat bodies in our culture are often constructed as emotionally out of control and psychologically ill (Lupton 2013). Part of this is due to greater rates of depression and mental illness in fat populations, in large part due to the daily stigma they face (Bacon 2008; Bacon and Aphramor 2014). But many fat studies scholars assert that this is another instance of the continued medicalizing of fat bodies (Lupton 2013; Rothblum and Solovay 2009). In my conversations with clinic psychologists, they informed me that trauma, addiction, and other mental illnesses are a part of many—but not all—bariatric patients’ stories. For Joe, this image of himself at his fattest did elicit real feelings of depression.

Western culture’s aesthetic of health constructs fat people as unhealthy moral failures. However, sudden weight loss can also be a sign of serious illness, especially for older people with known chronic illness. When Larry first started losing weight, friends and acquaintances were afraid to approach him because they thought he had become terminally ill.

I remember even for someone who just saw me didn’t know I had

[bariatric surgery], they were afraid to approach me, thinking I was dying.

Because you lose weight and they say people lose weight because they’re

dying. A lot of people say that, a friend of mine told me that. He says,

“You look a little pale, so I was afraid to ask something.” He needed to

ask what was wrong with you. I tell everybody right away. I’m very open

about it. “Yeah, I had weight loss surgery a year ago.” “Okay that’s good.

How do you feel?” “I feel great.” That’s the whole thing. – Larry, 65,

white, retired firefighter and small business owner

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Larry’s sudden and significant weight loss set off alarm bells among people who knew him. He had a history of serious illness, including a disabling, chronic, genetic condition.

Larry is also a white man of an advanced age, a group that people do not typically associate with dieting. Now Larry is open about his surgery and makes sure that people in his social network know that his weight loss represents a health intervention, not a serious health issue.

The African-American women I interviewed expressed concern that they did not want to lose “too much weight.” They wanted to look “healthy” and avoid looking “sick” or “on drugs.” Marlene—47, Black, retired medical assistant—believed that the goal weight her surgeon suggested at her consultation was too low.

Marlene: I want to go down to between 160 and 175.

Corey: How did you arrive at these numbers?

Marlene: [The surgeon] told me his goal for me was 150 pounds. I’m 280

now and I didn’t want to look like I’ve been on drugs. I want to make the

weight loss for the health, and I think that would be a healthy little weight

for me.

Fatness is associated with bad health behaviors—i.e., too much food and too little exercise. But for the Black women I spoke to, too much weight loss is indicative of illness or other negative health behaviors like drug use.

Aesthetics of health are constructed not just in gendered ways (Spitzack 1990) but also according to age, race, and other identities. On the one hand, African-American women in this study may be responding to the greater health risks faced by African

Americans compared to their white counterparts (Williams 2012); in a community

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plagued with chronic and acute illnesses, a sudden drop in weight can be alarming. On the other hand, there is evidence that African-American women face different beauty standards compared to white women. The evidence for this is mixed. Some scholars suggest the pressure is growing among African-American communities to conform more closely to white standards, especially among African-American women who are upwardly economically mobile (Fikkan and Rothblum 2012). African-American women in this study expressed dissatisfaction with their bodies for aesthetic as well as health reasons, similar to the white women and the men I interviewed, but with the caveat that they did not want to appear “too skinny.”

In contrast, some white women expressed that they could not be thin enough.

Some white women express a desire to weigh less than the number the surgeon recommends48. Pauline, a former nurse, expressed a desire to weigh less than the 180- pound goal her surgeon suggested for her.

Pauline: My fantasy goal weight is 135–40, but that's just fantasy. You

know. Yeah, if I get down to 180, I will be more than happy. More than

happy. If I get down below that, that's just a bonus. I plateaued there for a

while but I'm on a downward trend again.

Corey: So how did you arrive at your goal number and your fantasy

number?

Pauline: Well, at 160, which is what I was when I went into the Army… I

probably dropped 5 or 10 pounds in the Army but put on muscle. But that

48 Especially women in the “honeymoon stage” in the months after surgery when patients lose weight rapidly 173

is actually a more than excellent weight for a 20-year-old. For my age 20–

30 more pounds is fine. Now if I ever happen to want to model or, you

know, be one of those 5 foot 11—I'm not 5'11"—125 pounders, you

know… but I'm 5'9". I could probably weigh 135, but I think I'd probably

look sick.

Corey: Where did the 135 number come from?

Pauline: Never weighted that before. It's 25 pounds underweight49.

For Pauline, a desire to weigh within the underweight range on the BMI chart was a fantasy. Being underweight would put her at even greater health risk than being overweight (Bacon and Aphramor 2014; Campos et al. 2006). She does also acknowledge that at this weight she might “look sick.” But the promise of achieving the white, class- privileged, thin ideal—even at the expense of health—is still a fantasy for many women.

“Skin Everywhere”

Bariatric patients undergo surgery in order to exit the stigma of obesity. Some patients do find some success in this endeavor. They find it easier to move not just because of their lighter weight, but also because they find themselves free of the constrictions of being too large for the built environment around them. Strangers are friendlier. Friends and acquaintances compliment their appearance. Patients find themselves moving through the world with more confidence. Almost all of the patients I interviewed were pleased with their decision to undergo surgery and felt much better about their bodies and themselves.

49 Pauline is referring to the BMI standards. According to her height, weighing 125 pounds would give her a BMI of 18.5 which is considered “underweight.” 174

I asked patients whether they saw themselves as thin after bariatric surgery. The majority of patients—including those who appeared thin—said that they still considered themselves to be fat. For Gabby—50, white, retail worker—despite losing a great deal of weight and even undergoing some cosmetic surgery, she still saw the same fat person in the mirror.

Gabby: Like, if I'm standing in front of the mirror naked, I don't see

anything different than I did before the surgery… I carry all my weight on

my hips and my thighs and I do think that that part has gotten… it's almost

like some of it shifted. So some of it is, like, the sagging skin and all that

is kind of all down there where I look and I'm like, yeah, I still have a big

butt and I still have big thighs and you know. So I don't think I see my

body any different now than I did then.

Corey: So you would describe yourself exactly the same now as you

would then? Does that make you regret getting surgery at all?

Gabby: No, because in my head I know that it's different. But you still see

that… it's hard to see past what you're used to seeing in the mirror all the

time.

Gabby had a hard time seeing herself as thin because she did not view her body as radically different after weight loss surgery. She still had very negative feelings about her body and how she looked.

Charlotte did not believe that she would ever see herself as a thin person because her fat body has been a part of her identity for a long time.

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I would love to be [thin] but I don’t think I would ever see myself that way

because this is how I am. You know what I mean. This is how I’ve always

been, so even if I was, like, size 10, I wouldn’t see that. I would see cute,

chubby Charlotte, that’s just how I’ve always been. I don’t think I would

ever consider myself thin. – Charlotte, 53, white, disabled former

accountant

For Margret—36, white, temporary homemaker, former ER tech—her body image represented part of her anorexic illness identity.

Margret: I don't think people see me as a thin person since I went through

surgery because I still don't see myself as a thin person… what I see, that's

part of the eating issue. Like, you can actually reverse and kind of go

anorexic. Because when I look in the mirror I still see that 300-pound

person. So it's hard for me to think that other people see me as thin when I

don't feel that way myself. But I mean, people have made comments like,

"Oh, you know, you should probably back off from, you know, doing such

and such exercise ‘cause you're starting to look too thin.”

Corey: Yeah, I know [your sister] had said something to me when she told

me about you. She said that she was worried about your exercise and

things like that.

Margret: Yeah! Yeah! Because I do, like, I have to justify everything that I

eat with an exercise. And I do see a counselor and stuff because that's why

I say you can, you can actually revert and go the other way.

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In this case, going “the other way” means obsessively exercising and restricting calories—as opposed to being inactive and consuming too many calories. Margret continues to see the counselors at the bariatric clinic for symptoms of anorexia—which is characterized not only by restrictive eating and compulsive exercise, but also by distortions in a person’s perception of their own body (American Psychiatric Association

2013).

Even patients who might be considered successful in terms of weight loss do not fully identify with the privileged status of thin. In fact, not a single patient identified or felt that others identified them as “thin” or “skinny.” Instead, successful post-surgery patients consider themselves “normal” or “healthy” or at the very least “less fat.”

Defining oneself as “healthy” or “normal” does represent stigma exit to some degree.

Much of the previous literature has focused on the internal components of the process of exiting a stigmatized obese identity—focusing on body image or self-concept (Carr and

Jaffe 2012; Granberg 2011). However, these studies often only mention in passing the marks that being fat leaves on the body.

In her ethnographic account of bariatric patients, Natilie Boero (2012) noted patients’ expectations about weight loss often do not match the expectations of the medical profession. According to the American Society for Metabolic and Bariatric

Surgery (ASMBS), a bariatric patient is successful if they lose half of their “excess body weight” and maintain this weight loss (ASMBS n.d.; Boero 2012a). For many patients— especially those who are very large before surgery—half of their excess body weight still leaves them in the overweight or obese categories medically and they often appear fatter than “normal.” For patients in this study, their own goals were not based in the ASMBS

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ideal, but rather from several other sources. For many, their goals were based in conversations with their surgeon. Patients also referenced medical standards like the

BMI—though most were critical of this standard and believed the staff at the clinic to be critical as well. Many patients collected information from online sources and support groups which also influenced their own goals. For many the focus was on how much they weighed in the past—at their lowest weight.

I heard people say, “What did you weigh in high school?” Sort of like what

could your body be? What should your body maybe be before college and the

freshman 15 and having kids and whatever it is? I mean there are people who

are overweight in high school, but it’s kind of like it’s, some people have

asked that before. I think, like, information sessions or something kind of as a,

like, “This is the way your body could be or your body would know how to

be.” – Nichole, 44, white, medical doctor

As I discussed in chapter 3, bariatric bodies occupy a tentative status as healthy or

“normal.” They must maintain a constant surveillance and discipline over their bodies to prevent themselves from sliding back into their former obese embodied identities.

Surgeons and other clinic staff inform patients that weight gain after about a year post- surgery is normal—as long as it is within 10 to 20 pounds. Of the patients I spoke to who were a year or more post-surgery, only 3 had not experienced weight gain. The majority reported gaining anywhere from 15 pounds to 100 pounds after surgery. For these patients, their goals always focused on losing those pounds they had gained post-surgery.

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I'd like to be as low, lowest I was… was, what was it? Subtract 189 from

351. Oh, I got a pen, why don't I figure it out? I was happy there… 162.

That's my goal weight. – Erma, 75, white, retired realtor

The fact that Erma knew to a very specific degree how much she weighed and how much she had gained is a testament to the way bariatric patients closely surveil their own bodies. Even patients who gain only a few pounds post-surgery fret over losing them as quickly as possible.

I’m going to do what I’m supposed to do, so I try to do it. Because weight

does come back and I have gain some back since I lost. [sic] Yeah, oh,

definitely yeah, very frustrating. [sic] Dr. Dan told me, “You’re going to

gain weight back.” They say 10 to 20 pounds you put back. I’m like, oh

my God, if I gain 20 pounds back I’m, like, I’m going to freak out. I have

probably gained almost 20 pounds as well and I’m like, “Oh my God.”

I’m really kind of trying to lose back down at a certain point, because I

just don’t want to gain anymore. I would like to get back down and it’s

hard to lose it. Once you put a little bit back on, it’s hard to lose. I don’t

know why. You wouldn’t think it would be. – Jodie, 59, white, education

assistant

For the majority of bariatric patients, life after surgery—similarly to life before surgery—is about striving towards a weight loss goal. Patients in the pre-surgery phase and early post-surgery stages are striving towards a weight loss goal—often to lose more than 100 pounds. Those few who do meet their goals often move on to lower and lower goal weights.

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Yeah, but I still have about, my goal weight, in fact I set the goal weight

and the doctor said, “What do you think would be reasonable?” I said, “I

don’t know. I know I’m not going to get back to childhood weight or

whatever but like 140.” He said that’s doable so, yeah. If I, I’ve got 8

more pounds to that and I’d like to get down to 130. – Ellen, 62, white,

retired social worker

After a year or more, patients often find themselves gaining a few pounds and then the goal becomes returning to their lowest weights. At all stages, the bariatric embodied identity is all about striving for a weight loss goal. They never fully exit the stigma of fatness because their battle with obesity is never fully complete.

In marking their weight loss, clothing size is as important as the numbers on the scale for marking bariatric patients’ progress. Historically, the move in the 20th century towards the commercial production of clothing was an important part of the construction of fatness as a social problem. Clothing was no longer made in the home and tailored to the dimensions of individual bodies; instead, clothing was purchased in pre-determined sizes from stores (Stearns 1997). In contemporary culture, women’s sizes are divided into multiple different categories—there are plus sizes for large women, petite sizes for small women, and so-called “straight” sizes, which are the standard sizes carried in most stores.

The distinction between plus sizes and “straight” sizes is very important for women’s definitions of themselves as fat vs. “normal.”

I don’t have that expectation of being a thin person. I just think compared

to, I think if I’m wearing sizes, if I’m wearing non-plus sizes that might

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help. If I were wearing a 12 or 14 I might think okay, now I’m a normal

size person but that’s a long way off. – Nichole, 44, white, medical doctor

Others reported that they also did not consider themselves thin because they were still shopping in the “plus sized” sections of stores.

Even for patients who shopped for clothes in “straight sizes” and would probably be considered “normal” in terms of their body size, there are still embodied challenges to complete stigma exit. The most obvious and difficult-to-manage embodied marker of a former obese status is loose skin. The more weight the patient loses, the greater the amount of excess skin.

I mean, for the most part I'm happy with my choices that I made for

surgery. The only thing is the skin. Sometimes they don't tell you exactly

the, the extent of extra skin that your body will have. Like, of the hardest

things, because you look in the mirror and you're looking for different

changes, but you have all that skin everywhere. So it's hard to see, you

know, wow, I've accomplished this goal, because when you look in the

mirror you're expecting to see one thing and you just look like a deflated

fat person. – Margret, 36, white, temporary homemaker, former ER

technician

An obese embodied identity is a discredited identity because a fat body carries visible stigma. A bariatric embodied identity is often a discreditable identity. Most bariatric patients are choosy about the clothing they wear, choosing shirts, pants, skirts, and undergarments that conceal loose skin around their stomachs, thighs, and arms, and lift sagging breasts.

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The burden of this loose skin is experienced differently by younger women (40s and younger) and older women (those 50 and up). For one thing, younger bodies are better able to reshape loose skin—although young women still weren’t happy with the loose skin that remained.

But it’s then I realized the skin does not go away on its own, and at the

same time I realized that I didn’t really want the plastic surgery but now

I’m getting more like I might want it and my mom is, “We can’t afford it.”

Because many of the stuff I have qualifies for plastic surgery. I don’t have

that much, it’s like, yay, some of my skin bounced back, but it bounced

back too much. – Kelly, 29, white, disabled

For Kelly—the youngest woman I spoke to—her skin recovered and she did not have as much loose skin as a typical bariatric patient after significant weight loss. However, because her skin doesn’t hang low, she doesn’t qualify to have her excess skin removed by insurance50. Kelly had anxiety about how future lovers and husbands might feel about this skin. While younger women have less skin sagging after surgery, they experience a great deal of anxiety about it. As I mentioned above, these women often felt that they were struggling to meet life course demands of finding a partner and starting a family.

50 There are two plastic surgeries that can potentially be covered by some insurance. Breast surgery may be covered by some insurers (for any woman regardless of bariatric surgery status) if you can prove that your heavy breasts are causing you back pain or your bra straps are leaving marks in your shoulders. The surgery most bariatric patients seek that can be covered by insurance is the panniculectomy, where the skin that drapes down from the lowest part of the abdomen is removed. Insurers will typically cover this removal if the skin descends below the patient’s pubic hair and/or if the patient can demonstrate that the skin is at risk of infection. The removal of excess skin in other areas of the abdomen, back, arms, or legs is rarely covered by insurance since these procedures are considered cosmetic. 182

For older women, these demands were different. Most of them were married with grown children. While they still felt pressure to be attractive, this pressure felt less because of their age.

Then when you think about it, my body is not going to be perfect and you

want that thing that’s on People magazine. You want that body. I mean,

I’m 59 years old now. I guess [I had] my surgery at 55 [years old]. It is not

going to happen. – Jodie, 59, white, education assistant

Other women ages 50 and older echoed similar sentiments—they felt that, at their age, it was normal for their breasts and skin to sag, which seemed to help them to accept their bodies. However, Erma—75, white, retired realtor—and May—73, white, retired dental assistant—bantered about how, if they were younger, they absolutely would have their excess skin removed and tightened surgically. 51

Erma: And then I thought about having plastic surgery. So they stripped

me and took a picture of me. Stripped with my stomach hanging and my

boobs hanging and all that stuff. And that was humiliating. But then I

didn't do it.

May: And they tell us that if you have this big stomach—which I do—and

it hangs real far down and that Medicare will pay for it. But then if you

don't get the muffin done in the back52. I don't know. I'm 73 years old it's

kind of like, oh well.

51 I interviewed good friends Erma and May. They are neighbors who become good friends when they discovered that the other was going through the pre-surgery process around the same time. The surgeon refers to them as “sidekicks” because they are usually in each other’s company at the bariatric clinic. 52 Referring to fat deposits on the lower back often called “love handles” 183

Erma: Hey, if I was 20 years younger I’d have it.

May: Me too. I'd have it. I'd have them pull it all the way up.

Erma: I would, I'd be able to wear sleeveless dresses

May: Oh yeah.

Erma: You know? Get rid of the long wings.53

May: Get rid of the long wings.

Erma: Yeah.

May: The boobs and everything that goes south.

Joe also found that his age and gender helped him cope with another appearance-altering bariatric symptom—hair loss.

One thing that I guess complained about was they said, like, after about 5,

6 months you’ll start losing some of your hair... [the surgeon said,] “You

probably won’t lose hardly anything.” Well, I do lose some, but not what I

thought it would be. Being 64, I’m going to lose my hair anyways, what’s

the difference? – Joe, 64, white, retired dairy plant supervisor

Many bariatric patients experience hair loss because it is difficult for their newly reconfigured bodies to absorb nutrition. In fact, a number of patients add biotin—to prevent hair loss—to the list of vitamins and supplements they take. For many women, this is a scary prospect, but for Joe—because of his age and gender—a little hair loss did not worry him. His hair was already thinning before surgery.

53 Referencing the skin that hangs off of the upper arms of people who lose significant weight. These “wings” were a common complaint of bariatric patients about their bodies. 184

As many patients discussed, there are surgical procedures for removing excess skin. While many patients consider plastic surgery, most do not undergo body sculpting because of the expense. Only a few of these procedures are commonly covered by insurers—most are considered cosmetic. A few patients had undergone plastic surgery.

Joanne showed me the long scar on her underarm from where they removed excess skin from her arms. Joanne was quite content with the results, but other patients worried about the long scars left after removing skin. Gabby was happy with the results of her breast lift but was very unsatisfied with the liposuction she had done on her thighs.

Finally, last year, my husband convinced me, "Go get the thigh surgery

done." So I went and it's two parts. The first thing you had to do was

liposuction. So now it's even worse, because now it's like missing fat so

now it like really jiggles. And I'm like, ok, now it's another probably 8,000

dollars to do the second part of it. Do I really want to spend that

money? And you know, I struggled with the first part of it. It took me 9

months to make the decision to do that part and most of it was the money

side of it. It was, do I really want to spend this? And my husband's like,

"Just do it. You know it's going to make you feel better." My girlfriend

told me the same thing. She's like, "You know it's something that you

want to do." She said, "You know it will make you feel better." And now

I'm like, ok, that part didn't really do what I wanted it to do now do… and

even the nurse when I went in for my last follow up, she's like, "You really

need to do the next step. You're not going to be able to tell anything." She

said, “You'll like it much better.” – Gabby, 50, white, retail worker

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As discussed earlier, Gabby has a difficult time with body image issues after surgery—

especially when it comes to the lower half of her body. She underwent the first part of the

procedures to have her thighs sculpted. She felt like the procedure made her loose skin

worse and was reluctant to have the second part of the surgery—especially since the first

cost her $8,000 out of pocket. Her husband, friend, and even a nurse have tried to

convince her to finish the procedures, but the idea of spending so much more money for

something she might not even be totally happy with seems too risky to Gabby.

Lucy had mixed feelings after her surgery. She had major complications and was

hospitalized from her liposuction54. A lot of this dissatisfaction came from gaining back a

significant amount of weight. But she also discussed not being completely satisfied with

her plastic surgery and believed that other bariatric patients do not look good after plastic

surgery.

I have seen some people that have lost, like, a couple of 100 pounds, and

they start having a plastic surgery. Some of them don’t look good. I was

surprised… they looked funny. And my stomach is never going to look

like it did. Not because it didn’t heal properly, it’s because of the surgery,

it’s not. I don’t think it truthfully is perfected yet. I don’t know. Maybe if I

was a skinny mini, a tiny little thing, which I will never be, it would look

54 Even after her traumatic bleeding experience from her surgery, Lucy wanted to get more plastic surgery done. She especially regretted not getting more skin removed from her back. Her doctor, however, told her she should not get any more surgery. He argued that because she was addicted to food before bariatric surgery, she could transfer that addiction to plastic surgery. This idea of transferring addiction from food to another substance (like drugs and alcohol) or behavior (like compulsive shopping or sex) was commonly held by patients and providers at the clinic. 186

different but it just, even after I had [plastic] surgery, it still did not

look…like it did before – Lucy, 66, white, retired medical technician

Lucy felt that, despite the surgery, she could not fully look like the thin, toned ideals she sought through plastic surgery. Even with successful weight loss and plastic surgery, bariatric patients still bear the scars and markings of their former obese embodied identity.

Conclusion

Appearance is more than just skin deep. The way bodies appear to others— especially their size and shape—conveys important symbolic meaning. In the context of the bariatric clinic, fatness is laden with meanings about health and morality (Jutel 2005), meanings which intersect and construct one another in complex and often contradictory ways. Bariatric patients carry these meanings on their bodies. These are meanings which have real consequences for their life chances—often limiting class mobility and disrupting life course trajectories. Given the consequences of fat stigma, it’s not surprising that Pauline would see her daughter’s weight as disfiguring like a facial deformity. For Pauline, Polly’s weight is a social emergency that requires surgery.

Fat people carry a visible stigma. The appearance of their fat bodies triggers bias in other people and discrimination from institutions; this is especially true for women.

For women, it can create extra difficulties in achieving different milestones in the life course—specifically, getting married and having children. Furthermore, fat embodiment prevents white, class-privileged women from fully embodying ideal white femininity— despite how successful she might be, a fat white woman cannot fully access her middle- class, white privilege. Fat people internalize their fat stigma, feeling shame and anxiety

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about how they are perceived by strangers and even family, friends, and partners. For fat people—especially fat women—appearance concerns are far from frivolous. The visible stigma carried by fat people limits their life chances.

Bariatric patients construct a moral dichotomy between health and appearance.

Obtaining bariatric surgery for health reasons—like to improve mobility or prevent diabetes—are “the right reasons” to undergo bariatric surgery. Obtaining bariatric surgery for cosmetic reasons—to appear attractive to potential partners or look good in your clothes—are “the wrong reasons” to undergo bariatric surgery. Given the moral supremacy of health in contemporary Western society (Crawford 1980; Metzl and

Kirkland 2010), it’s not surprising that bariatric patients value health. For a few bariatric patients, constructing health in opposition to appearance is an attempt to resist oppressive beauty standards. More often, bariatric patients reframe their surgery as a health issue to distance themselves from the stigma against cosmetic surgery.

The stigma fat people experience is magnified by their status as “unhealthy others” (Crawford 1994; Kwan and Graves 2013). The “aesthetics of health” in American culture construct fat bodies as unhealthy moral failures, based solely on their appearance

(Jutel 2005). Patients evaluate their bodies according to this aesthetics of health, often describing their pre-surgery bodies as “looking unhealthy.” The clinic furthers this construction by marking patient progress through photographs and displaying successful weight loss in patient fashion shows.

Of course, this aesthetic of health is further complicated by other dimensions of identity—such as age, gender, and race. For older patients, their sudden weight loss can trigger alarm among friends and family who don’t know about their surgery—especially

188 for men who do not have a history of dieting. African-American women did not want to lose too much weight for fear of appearing “sick” or “on drugs.” Different beauty norms and greater health concerns may contribute to Black women’s desire to not get too thin.

White women, on the other hand, cannot be thin enough due to the construction of ideal, white femininity.

Patients undergo bariatric surgery to escape the visible stigma of obesity.

However, patients face many barriers to fully achieving stigma exit. While previous research has discussed social and cognitive issues which prevent full stigma exit (Carr and Jaffe 2012; Granberg 2011), I discuss the embodied barriers to full stigma exit. The difficulty in losing weight and the impossibility of the thin ideal leads many bariatric patients to continue to focus on weight loss. Most bariatric patients continue to fight against the return to the obese embodied identity—therefore never fully exiting the stigma of obesity. An obese embodied identity is always visibly spoiled—discredited in

Goffmanian terms (Goffman 1963; Saguy and Ward 2011). However, a bariatric patient who successfully loses weight still carries the markers of obesity on their body in the form of loose skin and scars. They may be able to hide these markers under their clothes.

Some patients choose cosmetic surgery to remove excess skin and fat tissue. Despite these efforts, the markers of their formerly fat body remain—leaving their identity forever discreditable.

Embodied appearance plays a key role in the construction of fat bodies as both unhealthy and immoral. Fat bodies carry visible signs of their status as a person who is

(or once was) fat.

189 Fat studies scholars have noted the importance of visible stigma (Gailey 2014; Rothblum and Solovay 2009; Saguy and Ward 2011). However, scholars who focus on fat stigma exit do not focus on the embodied nature of fat stigma. Furthermore, there should be further discussion of how embodied stigma is related to race, class, gender, age, and other identity characteristics. Identity is embodied and unless we examine how the body is experienced and viewed by others, we will never fully understand the nature of stigma.

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CHAPTER VI

DISSCUSSION

Identities are always embodied: our bodies are how we experience the world and govern how others interact with us. For bariatric patients, they come to the clinic with a spoiled, obese embodied identity. In our culture, fat bodies are highly stigmatized, constructed both as moral failures (Lupton 2013; Rothblum and Solovay 2009) and unhealthy others (Crawford 1994; Kwan and Graves 2013). Through the use of biotechnology and the hard work of adopting disciplined health behaviors, patients aim to exit the stigma of obesity—to shed not only the weight but the burden of their obese embodied identity.

Through the bariatric program, patients transition from the obese embodied identity to a bariatric embodied identity. In chapter 3, I explored this process using

Goffman’s (1963) concept of the moral career and Foucault’s (1979) ideas about discipline. The moral career of the bariatric patient proceeds through five stages: the dieting stage, the pre-surgery process, the recovery stage, the “honeymoon” stage, and the

“struggling” stage. In the dieting stage, patients are fully in the obese embodied identity; they repeatedly attempt to discipline their weight, sometimes successfully but only for a short period of time, following a yo-yo dieting trajectory. During the intensive pre- surgery process where patients are surveilled inside and out, they are also trained in the disciplinary discourse of “the program,” or how to surveil and control their own bodies.

After surgery, patients fully transition into the bariatric embodied identity. In addition to the discourse of “following the program,” an embodied disciplinary technology is

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employed where bariatric patients experience painful and potentially embarrassing bariatric symptoms if they fail to “follow the program.” During the recovery phase, patients are healing from surgery and learning how to integrate their reconfigured bodies and disciplined rituals into their day-to-day lives. The “honeymoon” is the first year when patients are losing the most weight. During this time, most patients are still experiencing bariatric symptoms and they are still connected to the clinic through regular checkups and support groups. The “struggling stage” usually a starts a year or so after surgery. This is when patients begin to lose symptoms and lose ties to the bariatric clinic. Over time patients lose both the discursive and embodied disciplinary technology that enabled disciplined weight loss. Some patients begin to slide back into an out-of-control obese embodied identity.

The moral career of the bariatric patients involves disciplining the body through a discourse where patients learn to see “following the program” as moral impetus. For patients, “following the program” becomes a basis for judging themselves and others.

Weight gain is attributed to not adequately “following the program” and judged as a moral failure. The process is not only discursive but also embodied through the reconfigured digestive system which physically punishes bariatric patients if they eat too much, too fast, or if they eat the wrong thing. This discipline is designed to counteract the body’s natural resistance to weight loss. Both the discourse and the embodied disciplinary technology work together to reinforce the lessons of “the program.” The relationship between the obese embodied identity and the bariatric embodied identity is not a single line progression; instead, it is more fluid. As time moves on from the surgery, the body heals and adjusts and begins to resist control.

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In chapter 4, I analyzed bariatric patients’ embodied experiences of health and illness. The findings illuminate the construction of the obese embodied identity as an illness identity. Obese embodiment is constructed as a trap. Patients find their ability to literally move around in the world limited by their embodiment through low fitness and/or the pain of age, disability, and injury. Patients are also not free to move around the built environment, which privileges young, thin, able bodies—essentially disabling fat bodies. Furthermore, patients are confined by shame: the shame of visibly struggling to move and not fitting in further confines the obese embodied identity.

Patients also construct health as a freedom from medication. Patients mark their transition from an obese embodied identity to the healthier bariatric embodied identity by counting down the number of medications they regularly use. Not only does this provide an indicator of improved health, medication represents illness symbolically (Conrad

1985). After surgery, patients add a number of vitamins and supplements to care for their reconfigured bodies’ diminished capacity to absorb nutrients. Patients undergo regular blood work to adjust their diet and supplements. Supplements must be taken in a regimented way (only a few at a time, certain vitamins can’t be taken together, etc.) and are not totally free of side effects or cost. Even though patients often take as many vitamins as they did medications—sometimes more—vitamins and supplements do not carry the same moral weight as medication for chronic illness. Rather than being a sign of an impaired digestive system, they are a sign of morally superior self-care through health behaviors. Bariatric embodiment is not framed as disabled but rather as healthy or at least healthier.

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Bariatric patients experience a number of painful, uncomfortable, and embarrassing symptoms which would be a sign of illness in many other bodies. However, these symptoms are reframed in such a way that patients do not experience their bariatric embodied identity as an illness identity. Four strategies for normalizing bariatric symptoms emerged from this data. First, bariatric patients often frame these symptoms as a normal part of the healing process. Second, they adjust their normal routines and attitudes to accommodate bariatric symptoms.

Third, and perhaps most importantly, patients understand that bariatric symptoms are a part of the disciplinary process: they punish the body for certain eating behaviors and limit what nutrients can be absorbed. The abatement of these symptoms over time is not celebrated as a return to normal, but instead represents an end of the “honeymoon stage” and an increased threat of remission to an obese embodied identity. Patients often attribute the loss of these symptoms to undisciplined eating habits which stretch the pouch—reinforcing the moral lessons of “following the program.”

Fourth and finally, bariatric patients view their symptoms as worth it. The weight loss and the freedom from the discredited obese embodied identity make living with bariatric symptoms tolerable. Even those patients who gain weight or have serious complications do not regret their surgery; they often appreciate the taste of freedom from their obese embodied identity. These normalization strategies, combined with increased mobility and decreased medications, mean that bariatric patients are able to construct their bariatric embodied identity as healthier.

In chapter 5, I explore the complex relationship between health, appearance, and morality. Health is seen as a moral good among bariatric patients, which is not surprising

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given the new health morality that is so pervasive in Western culture (Metzl and Kirkland

2010). Bariatric patients believe that it is morally superior to focus on health outcomes of bariatric surgery over appearance concerns. However, appearance conveys both stigma and health status through an aesthetics of health.

The aesthetics of health and visible stigma bariatric patients experience are shaped by race, class, gender, and age. For instance, appropriate white feminine embodiment is heavily tied in with size and weight—especially for those who are class privileged. For white women, they cannot be skinny enough—especially unmarried women without children who are seeking to meet these important life course events. The

Black women I spoke with also experience the aesthetics of health where thinness is privileged over fat—but they also fear appearing too skinny, which might convey illness or drug addiction. Older white men also experience concerns by others when they suddenly lose weight—fearing that they’ve suddenly become very sick.

One of the paradoxes of bariatric embodiment is that bariatric surgery is undertaken to exit the stigma of obesity, and yet bariatric patients do not view themselves as “thin” no matter how dramatic their weight loss. Those who are most successful may view their embodiment as “normal,” but for most they never fully exit the stigma of obesity. Previous research suggests that much of this is due to identity lag, where patients’ identities have not caught up with their embodiment (Granberg 2011). However,

I argue that the bariatric embodied identity cannot fully exit the stigma of obesity because of embodied markers of their former obese status. For some, they are not satisfied with their weight loss or they gain more weight after surgery—meaning that they are still in pursuit of weight loss and never fully exit the obese embodied identity. Even the most

195 successful patient carries loose skin and/or plastic surgery scars. These markers of a former obese embodied identity can be hidden from view—meaning bariatric embodied identity moves from a discredited identity to a discreditable identity.

Theoretical Implications

The findings from this project have implications for a number of different sociological and interdisciplinary literatures. In this section, I will describe the theoretical implications for social scientific literature on bariatric surgery, fat studies, sociology of bodies and embodiment, and sociology of health and illness—specifically illness experience and medicine as an institution of social control.

This study contributes to the growing social science literature on bariatric surgery by providing a detailed analysis of the discursive and embodied mechanisms through which bariatric surgery operates. Control and surveillance of bodies through dieting does not work for the vast majority of those who do it. The material—biological, hormonal, genetic—reality of the body resists weight loss because its impetus is to protect itself from starvation (Bartky 1990; Mann 2015). Knowledge/power enacts on the body through the biomedical technology of bariatric surgery, modifying the material body so that it can be disciplined through surveillance (Foucault 1979; Meleo-Erwin 2012;

Morgan 2011; Throsby 2008a). But as the years go on, the body begins to heal, stretch, adapt to the modifications made to it and resume its resistance to discipline—if not fully, then at least to some extent. This has implications for understanding medicalization as a form of social control, identifying the way that biotechnology controls the body of both a symbolic and material level.

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These findings have implications for the study of bodies and embodiment more broadly. Examining how the body is shaped by biotechnology, but also how the body resists control, furthers our understanding of how the body is simultaneously an object and a subject (Bartky 1990; Budgeon 2003; Featherstone and Turner 1995; Moore and

Casper 2015). I suspect that similar mechanisms are at play in other embodied identities, such as trans people seeking surgery for gender reassignment, the medicalization of aging and ability, and anyone else using biotechnology to discipline their bodies and coming up against the body’s natural tendencies towards growth, healing, aging, and dying.

This study demonstrates how bariatric surgery functions as a tool of stigma management. Studies have shown that formerly fat people do not often totally exit the stigma of obesity (Blaine et al. 2002; Carr and Jaffe 2012; Fee and Nusbaumer 2012;

Granberg 2011; Mattingly et al. 2009). For bariatric patients, this can be even more stigmatizing because the manner in which they lose weight is viewed as morally inferior to losing weight using traditional diet and exercise without surgery (Drew 2011; Hansen and Dye 2018; Mattingly et al. 2009; Trainer et al. 2017). Much of the research on this has focused on the responses of others to the formerly obese (Blaine et al. 2002; Fee and

Nusbaumer 2012; Mattingly et al. 2009) or attributed this phenomenon to identity lag

(Granberg 2011).

I argue that embodiment is central to the issue of incomplete fat stigma exit.

Failed weight loss goals and regained weight means that the process of losing weight is never fully finished. In addition, loose skin and surgical scars all leave the mark of a former obese embodied identity. These findings suggest that bariatric surgery cannot be thought of as a technology of stigma exit. For most patients, full stigma exit will not

197 occur. Instead, it’s better to think of bariatric surgery as a tool of stigma management.

Weight loss from surgery takes a stigmatized identity that is visible—therefore always discredited—and grants patients the capacity to render their former fat status discreditable. Unlike fat embodiment, surgery scars and loose skin can be hidden under clothes. People can hide their status as a bariatric patient. They still carry embodied stigma, but this stigma is far easier to manage in interaction, which results in more friendly, kind, and complimentary responses from others.

As Goffman (1963) noted, often when a stigmatized person tries to exit a stigmatized identity, they are left marked as a person who formerly carried that stigmatized status. This is certainly true of fat people who continue to feel the stain of obesity stigma on their identity and the evidence on their skin. Other embodied stigmas leave a person physically marked as a former deviant: prison or gang tattoos, the embodied challenges of transitioning form one gender to another, burns and scars from cancer treatment, track marks from heroin addiction, etc. More research should explore the role that embodiment plays in managing a stigma that is written on the body for all to see.

These findings also have implications for fat studies. In keeping with feminist methodology (Fonow and Cook 2005) and fat studies (Rothblum and Solovay 2009), this work is grounded in the embodied experiences of fat people. More specifically, this study includes the voices of people who are considered outliers in terms of their weight—the people the medical establishment has labeled morbidly or even super obese. Patients who are significantly larger than prescribed body norms are even more vulnerable to fat stigma (Carr and Jaffe 2012). In her autobiographical memoir, Roxanne Gay (2017)

198 writes about how she agrees with the tenets of fat acceptance but finds it difficult to

accept her own body in the face of the difficulty, shame, abuse, and physical pain of

living in a very large body. She cites these struggles as the reason why she reluctantly

chose to undergo bariatric surgery (Gay 2018).

Fat acceptance/liberation and HAES have identified flaws in the narrative which equates fat with illness and thinness with health. They make compelling arguments that the collective anxiety over the obesity epidemic as a public health crisis is more moral panic than a clinically and statistically supported reality (Bacon and Aphramor 2011;

Campos et al. 2006). Studies have shown that fat people who engage in regular exercise, eat healthy food, and practice other health-promoting behaviors may not lose significant amounts of weight. However, they can improve their health dramatically and reduce their risk for chronic illness (Bacon and Aphramor 2014); this is one of the bases for the

HAES philosophy (Bacon 2008).

In some ways, however, the rejection of a pathologized construction of fatness has created a healthist construction of “good fatties” who work out and eat right and “bad fatties” who do not (Ragen Chastain 2016). Pathologizing and stigmatizing rhetoric about fat and health should be challenged, but we do need to acknowledge that fat people do have unique health challenges because of their weight, especially those whose bodies are outliers in terms of their weight. Just as it doesn’t serve African Americans to ignore their increased risk for heart disease, so too it doesn’t serve fat people to ignore our own increased risk for chronic illness. But it also doesn’t serve either of these communities to individualize and stigmatize the issues as one solely of unhealthy (morally corrupt) behaviors. For a more nuanced look at the issues of health, disability, and fatness, we

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need to bring the margins to the center (hooks 2000). We need more than just the stories of privileged young, health fat athletes and fashionistas. We need to hear the voices of fat people who are ill, disabled, and outliers in terms of their size. We need to attend to the needs of those in our community who struggle with trauma, illness, and disability. We need research that helps us to humanize their experiences and understand to their struggles.

This study contributes to our understanding of the illness experience. Patients’ experiences of health and illness are shaped by dominant discourses about health, appearance, and fat stigma. For example, in chapter 4 I discuss how patients normalize bariatric symptoms where others might view them as signs of illness. Furthermore, these discourses are constructed along with other embodied identities of gender, race, class, age, and (dis)ability. For instance, in chapter 5 I describe how the aesthetics of health are shaped by intersecting identities. What it means to look healthy for a white woman is different for a Black woman or a white man. What it means to have a healthy body image differs for older women who expect to have sagging skin and breasts than for younger women who are trying to meet life course goals of getting married and starting a family.

Limitations and Future Research

Since this is a small-scale study conducted in one location, the findings presented here are not generalizable to bariatric patients in general. I would even hesitate to apply these findings to all patients who undergo the bariatric surgery process in this clinic from which respondents were recruited. Given that I recruited many of my participants through support groups and clinic bulletin boards, I’m only accessing those patients who are actively involved with the clinic. Talking with long term, post-surgery patients, I learned

200 that patients lose contact with the clinic. This means I may be losing patients who are a) doing very well on their own and no longer feel they need the clinic, and b) doing very poorly and avoiding the clinic out of shame or resentment. In addition, one of the clinic psychologists generously offered to hand out my business card and let patients know about the study. She informed me, however, that she would only hand them to people she felt were mentally healthy enough to do a research interview. This may have biased my data towards people who were perceived by clinic staff to be more positive about the bariatric experience. Where this data lacks generalizability it makes up for in the richness of the data. One of the benefits of smaller, qualitative research studies is that they provide an in-depth look into patient experiences (Charmaz and Olesen 1997).

Very few men, LGBT people, and people 40 and younger participated in this study. No people of color (outside the Black/White binary) participated in this study.

Much of this is representative of the bariatric patient population—which is largely white women. However, my study skewed older than the general bariatric population (Martin et al. 2010). There is no data on the prevalence of bariatric surgery in the LGBT community—only one participant in this study openly identified himself as gay. This study could have benefited from more voices from the margins.

This data is cross-sectional, with patients from those who were undergoing the pre-surgery process to those who had undergone surgery over a decade ago. While this cross-sectional approach allows us to investigate a lengthy career in a shorter amount of time, a longitudinal study would give an even stronger look at how patient identity changes over time. Fortunately, all participants agreed to a follow-up interview. I would

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like to interview participants at least one more time before reworking this dissertation into a book manuscript.

Another possibility is gaining entrée to a new bariatric clinic to extend these findings. Specifically, I’m interested in looking at how bariatric patients construct their goal weights. What significant others are most important in this decision making— physicians and medical staff, friends and family, other bariatric patients, online support groups? I want to understand what role, if any, weight loss goals had on patients’ long- term well-being. How do these goals change over time? I believe that this research will have important implications for the treatment and well-being of fat people in health care contexts.

I’m also interested in potentially exploring other ways that people experience their embodied identities around weight and size. I would like to pursue the construction of food addiction and binge eating disorder. These are other places where deviant behavior—i.e., gluttonous, out-of-control eating—becomes medicalized. I could approach this through either a historical analysis or I could gain entrée into a binge eating clinic and/or food addiction support group to conduct interviews and field observations.

I’m also considering studying the embodied identities of people involved in body positive and fat acceptance/liberation. I’m considering approaching this methodologically by analyzing content published by popular body positive accounts and using popular

#hashtags. I’m also certain that I could recruit a number of popular online body positivity advocates to do interviews. This would yield a study of a fat embodied identity—a more critical discourse about fat stigma, health, and appearance—to contrast with obese and bariatric embodied identities.

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214 APPENDICES

215 APPENDIX A

IRB NOTICES OF APPROVAL

216 217 218 219 220 APPENDIX B

RECRUITMENT FLYER Participants Needed Bariatric Bodies Project

Bariatric Surgery Patients wanted for research to learn more about their personal experiences, thoughts, and feelings related to bariatric surgery, health, and body image.

Participants must be at least 18 years old and have undergone or are planning to undergo bariatric surgery. One hour interviews will take place at the University of Akron or a location convenient to the participant.

For more information please contact: Corey Stevens University of Akron Department of Sociology Olin Hall 247 Phone: (330)716-0942 Email: [email protected] [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stevens Corey [email protected] (330 Stev Corey ) ) ) ) ) ) ) ) ) ) 716 716 716 716 716 716 716 716 716 716 ------0942 0942 0942 0942 0942 0942 0942 0942 0942 0942 ens

221 APPENDIX C

PARTICIPANT DEMOGRAPHICS

Name Pre/Post Surgery Type of Surgery Gender Race/Ethnicity Age Occupation Education Amanda Pre-op and 4 Gastric Bypass Woman Black 50 Facilitator for a G.E.D. High School - Trade months post-op Program School Beverly Pre-op Gastric Bypass Woman White 48 Loan Specialist for a Associates in Bank Business Administration and Current College Student Bob 3 years post-op Gastric Bypass Man White 67 Retired Business Vocational School Owner (Machine Shop) Charlotte 1 year post-op Gastric Bypass Woman White 53 Disabled former Some College Accountant Darcy multiple surgeries: 5 Sleeve Woman White 31 Home Healthcare Masters in and 2 years post-op Gastrectomy then Worker Community Health Gastric Bypass Education Delphine Pre-op and 3 Gastric Bypass Woman White 55 Administrative Associates Degree months post-op Assistant Diana 3 years post-op Gastric Bypass Woman Black 57 Environmental High School Housekeeping Diploma Dona 2 years post-op Gastric Bypass Woman White 57 Research Associate for B.S. in Biology large hospital network Ellen 1 year post-op Gastric Bypass Woman White 62 Retired Social Worker B.A. in Psychology Erma 6 years post-op Gastric Bypass Woman White 75 Retired Relator High School

Gabby 1 year post-op Gastric Bypass Woman White 50 Retail Associates Degree Harriet 2 years post-op Gastric Bypass Woman White 57 Nurse Bachelors Jane pre-op Gastric Bypass Woman White 44 Unemployed and Associates in Health Disabled and Human Services Joanne 4 years post-op Gastric Bypass Woman White 56 Accountant MBA Jodie 3 years post-op Gastric Bypass Woman White 59 Education Assistant Some College Joe 5 months post-op Gastric Bypass Man White 64 Retired Dairy Plant Some College Supervisor Kari 5 months post-op Gastric Bypass Woman Black 46 Claims Adjuster for B.A. Insurance Company Kate 5 years post-op Gastric Bypass Woman White 41 Medicare Some College Reimbursement Specialist Kelly 2 years post-op Sleeve Woman White - Jewish 29 Unemployed and Some College Gastrectomy Disabled Kim pre-op and 1 month Gastric Bypass Woman White 44 Graduate Student in BSN and Working post-op Nursing on DNP Larry 1 year post-op Gastric Bypass Man White 65 Retired Firefighter and Some college and small business owner Military

222 Laurie 2 years post-op Gastric Bypass Woman White 73 Secretary at school for Some College developmentally disabled kids Lucy 9 years post-op Gastric Bypass Woman White 66 Retired Medical B.S. in Medical Technician Technology

Luke 1 year post-op Gastric Bypass Man White 61 Retired Business High School Owner (Machine Shop) Maggie 11 years post-op Gastric Bypass Woman White 49 Small Business Owner Some College Margret 1 year post-op Gastric Bypass Woman White 36 Temporary Trade School Homemaker; Former ER Tech Marlene Pre-op Gastric Bypass Woman Black 47 Retired Medical Associates Degree Assistant Martin 5 years post-op Gastric Bypass Man Bi-Racial: Black 59 Former labor lawyer, Law School and and Jewish Currently in works in Master of Law Human Resources May 7 years post-op Lap Band Woman White 73 Retired Dental High School Assistant Nichole pre-op and 2 months Gastric Bypass Woman White 44 Medical Doctor Medical School post-op Pauline 1 year post-op Gastric Bypass Woman White 59 Homemaker; Former Bachelors Nurse Pete multiple surgeries: 7 Lap Band then Man White 61 Data Architect B.A. in and 2 years post-op Gastric Bypass Mathematics Rosie 6 months post-op Sleeve Woman White 38 Customer Service and High School Gastrectomy Inside Sales Sally pre-op Gastric Bypass Woman White 59 Registered Respiratory B.B.A. Business Therapist (PRN) Admin and Res Therapy Degree Victoria Pre-op Gastric Bypass Woman Black 35 Nursing Aid Some College and EMT certification

223 APPENDIX D

INTERVIEW GUIDES

Interview guide (pre-surgery) Warm-up Tell me a little bit about yourself? Experiences Leading to Surgery How did you come to the decision to get bariatric surgery? Please, describe the processes you are going through to obtain surgery? - Appointments? - Classes? - Insurance issues? How did you feel about this process? - Did you think it was necessary? Useful? - Describe the most difficult thing about this process? Take me back to your last appointment - How did it go? - Who was it with? - What did you talk about? - How did you feel during and after this appointment? Tell me about the information staff and doctors at the clinic have given you about bariatric surgery? - How did you feel about this information? How often do you talk with other bariatric patients about their experiences? - What sort of things do you discuss? - How do these interactions make you feel about your own surgery? Tell me about the last time you talked with other bariatric patients? Tell me about some of the new diet and exercise regimes you’ve adopted to prepare for your surgery?

224 Describe how the staff and doctors talk about the surgery? - How did you feel about the way providers talked about the surgery? Tell me about the quality of care at the bariatric clinic? How would you compare the bariatric clinic with other experiences you’ve had with doctors or hospitals? Feelings about surgery Describe the typical response you receive when you tell people you’ve undergone bariatric surgery? How do you feel about your upcoming surgery? Do you feel prepared? Describe what the day you are getting surgery is going to be like? Please describe for me what you think it going to happen after your surgery? What are your plans for your recovery period? Social Reactions Take me back to the first time you talked to someone about your decision to undergo surgery? Who have you told about your surgery? - How do you feel they reacted to this information? How open are you about talking to people about your surgery? How have people responded to any changes in your body weight? Take me back to the last time you’ve told someone you’ve recently met about your surgery? Body Image and Changes What is your goal weight? - How did you arrive at this number? How would you describe your body before you started the process of getting bariatric surgery? - Probe: What do you mean when you say… How would you describe your body now? Describe some of the changes you’ve experienced in your body since you’ve started the process of getting bariatric surgery?

225 What does the word “obesity” mean to you? - Is this a word you would ever use to describe yourself? Do you ever worry about gaining the weight back? - If yes, tell me about the last time you felt worried about this?

General Feelings about Surgery How do you feel about your decision to undergo surgery? What advice would you give someone considering undergoing this procedure? Participant information

Name: ______Date of Interview:______

Gender: ______Race/Ethnicity: ______Age: ______

Date of Surgery: ______

Location of Residence: ______

Occupation: ______

Education: ______

Are you insured?: ______

Language Spoken in Home:______

226 Interview guide (post-surgery) Warm-up Tell me a little bit about yourself? Experiences Leading to Surgery How did you come to the decision to get bariatric surgery? Please, describe the processes you went through to obtain surgery? - Appointments? - Classes? - Insurance issues? How did you feel about this process? - Did you think it was necessary? Useful? - Was it difficult? Take me back to your last appointment - How did it go? - Who was it with? - What did you talk about? - How did you feel during and after this appointment? Tell me about the information staff and doctors at the clinic have given you about bariatric surgery? - How did you feel about this information? How often do you talk with other bariatric patients about their experiences? - What sort of things do you discuss? - How do these interactions make you feel about your own surgery? Tell me about the last time you talked with other bariatric patients? Surgery and Recovery Tell me about your recovery after surgery? Did you experience any complications or need to be hospitalized after your surgery? Would you please describe that/those experiences? Tell me about some of the new diet and exercise regimes you’ve adopted because of your surgery? Describe how the staff and doctors talk about the surgery? - How did you feel about the way providers talked about the surgery? Tell me about the quality of care at the bariatric clinic?

227 How would you compare the bariatric clinic with other experiences you’ve had with doctors or hospitals? Social Reactions Take me back to the first time you talked to someone about your decision to undergo surgery? How open are you about talking to people about your surgery? Who have you told about your surgery? - How do you feel they reacted to this information? Describe the typical response you receive when you tell people you’ve undergone bariatric surgery? How have people responded to any changes in your body weight? Do you feel people interact with you differently now that you’ve undergone bariatric surgery? - Please describe these differences Do you think people see you are a thin person now that you’ve undergone surgery? - What about you? Do you feel you are a thin person now? Take me back to the last time you’ve told someone you’ve recently met about your surgery? Body Image and Changes What is your goal weight? - How did you arrive at that number? How would you describe your body before you started the process of getting bariatric surgery? - Probe: What do you mean when you say… How would you describe your body now? Describe some of the changes you’ve experienced in your body since the surgery? Are there any differences in the way your body functions after your surgery? Can you describe these changes? Do you feel any differently now that you’ve had surgery? Can you describe these feelings? What does the word “obesity” mean to you? - Is this a word you would use to describe yourself?

228 Do you ever worry about gaining the weight back? - If yes, tell me about the last time you felt worried about this? General Feelings about Surgery How do you feel about your decision to undergo surgery? What advice would you give someone considering undergoing this procedure?

Participant information

Name: ______Date of Interview: ______

Gender: ______Race/Ethnicity: ______Age: ______

Date of Surgery: ______

Location of Residence: ______

Occupation: ______

Education: ______

Are you insured?: ______

Language Spoken in Home: ______

229 Interview Guide - New Post-Op Surgery and Recovery How are you feeling? How did everything go? Tell me about the time leading up to your surgery? Take me back to your time at the hospital. How did your recovery go? Tell me about some of the new diet and exercise regimes you’ve adopted because of your surgery? The Clinic How do you feel about Summa’s pre-surgery process now that you have undergone surgery? Do you feel you were adequately prepared? Would you change this process in any way? Describe how the staff and doctors talk about the surgery? - How did you feel about the way providers talked about the surgery? Tell me about the quality of care at the bariatric clinic? How would you compare the bariatric clinic with other experiences you’ve had with doctors or hospitals? Social Reactions How supportive where your friends and family during your surgery and recovery? How open are you about talking to people about your surgery? Who have you told about your surgery? - How do you feel they reacted to this information? Describe the typical response you receive when you tell people you’ve undergone bariatric surgery? How have people responded to any changes in your body weight? Do you feel people interact with you differently now that you’ve undergone bariatric surgery? - Please describe these differences Do you think people see you are a thin person now that you’ve undergone surgery?

232 - What about you? Do you feel you are a thin person now? Body Image and Changes What is your goal weight? - How did you arrive at that number? How would you describe your body before you started the process of getting bariatric surgery? - Probe: What do you mean when you say… How would you describe your body now? Describe some of the changes you’ve experienced in your body since the surgery? Are there any differences in the way your body functions after your surgery? Can you describe these changes? Do you feel any differently now that you’ve had surgery? Can you describe these feelings? What does the word “obesity” mean to you? - Is this a word you would use to describe yourself? Do you ever worry about gaining the weight back? - If yes, tell me about the last time you felt worried about this? General Feelings about Surgery How do you feel about your decision to undergo surgery? What advice would you give someone considering undergoing this procedure?

233 Participant information

Name: ______Date of Interview: ______

Date of Surgery: ______

Location of Residence: ______

Occupation: ______

Education: ______

Insurance: ______

234 APPENDIX V

MAXQDA CODE SYSTEM

Code System Memo # Code System 7581 Optifast Search for the word optifast 138 Intersecting Identities Because I want to be a good feminist scholar 0 Race Any Race related issue - comment on why 2 Gender Any gender related issue - comment on why 7 Media Any reference to fat people or bariatric surgery in the media 14 Career Anything that relates to the career of a bariatric patient or 4 the different stages of the process Journey Any instance of the word "journey" 34 Getting Fat Accounting of how a participant got fat in the first place. 33

Includes any accounting for weight status before bariatric surgery Fat Self This refers to the point when one starts to think of 9 themselves as fat. Dieting Stage This is the stage before surgery when patients are trying 92 other diets. Cultural Capital Any reference to gaining (or not gaining) useful cultural 14 capital towards bariatric surgery Choosing Surgery This code is for any accounting of how a person come to 54 choose surgery Research Any reference to researching the procedures before 87 choosing to undergo the surgery Knowledge is Power Any reference to knowledge being empowering or seeking to 7 know as much as possible Opposite People not findings research empowering 2 Soul Searching Any reference to really serious consideration of the decision 6 to undergo surgery Doctor Any reference to the role of the doctor in this decision. 48 Which Surgery Any reference to choosing a particular version of the surgery 38 (Roux-en-Y, Sleeve, or Lap Band) Others haveing Surgery Any reference to knowing someone who had surgery. 73

Media 3

232 Other Life Course Events Other events in the life course impacting 5 decision (e.g. retirement, marriage, etc.) Linked Lives Any reference to other people's lives being a 13 factor in choosing surgery Early Investigation Any reference to a period of time when a person 33 checked out surgery but was unable or willing to do it. Set Back Something outside of decision making that 2 caused participants to have to withdraw form the program or prevented them from joining the program Quit Anytime someone decided not to do the surgery 5 after starting the process Pre-Surgery Process Any reference to the Pre-surgery process that 198 Summa or insurance puts patients through. Feelings about process Any reference to how they felt about this 20 process Critical Any instance where the patient is critical of this 47 long pre-surgery process Steps in process Descriptions of the actual steps in the process 107 How Long? How long was their process 67 Why this process Any instance of participants accounting for why 66 the process exists in the first place Surgery Risk Any reference to them checking for surgery risk - 43 surgery risk is defined broadly and can include things that might make a person regain such as binge eating disorders Physical Health Any reference to testing for physical health risks 33 Dead Sleep Apnea Patient I'm trying to collect all the pieces of the story 3 about the dead patient with sleep apnea. Optifast and the liver Any reference to the purpose of Optifast to 8 prevent liver damage Social and Psychological Factors Any reference to surgery risks related to 22 psychological or social issues like eating disorders or not having the right social support Social Pulling out the quotes about specifically social 2 things Test of commitment Any reference to this process as a test of 39 someone’s commitment to the program Insurance Any reference to insurance dictating the process 35 or insurance companies as the reason for the process. Socialization Any reference to this process as a way to learn 88 about the surgery, diet and exercise, and how to manage after surgery Surgery and Hospital Time Any reference to the surgery itself of the period 65 of time they spent in the hospital.

233

Recovery and adjustment This is the period of time after a person leaves 156 the hospital when they are slowly moving from liquids to solid and learning what their body can and cannot tolerate Lap Band Adjustment Any reference to the process of adjusting the lap 4 band Tube and incisions Any reference to the tube or the litter laceration 24 marks on their stomach. Feeling Groggy and Low Energy Any reference to feeling groggy, low energy, 8 taking naps, etc. Pain and Pain Meds Any reference to pain or pain killers. 46 Back to Work/Movement Any reference to getting back to work or 50 exercise or any of the strenuous tasks of day to day life Food Process Any reference to the process of learning new 82 relationships with food. Socialization Process Any reference to the recovery eating as a 5 socialization process Nutrients - Protein Making sure that you are consuming enough of 8 certain nutrients - usually protein Experimenting with Foods Experimenting with what foods to eat 49 From Liquid to Solid The process of going from liquid foods to solid 50 foods after surgery. Vitamins Reference to the new vitamin regimen 2 Life long monitering This refers to the after-surgery period where 91 people have adjusted to their new bodies and are looking at a life of monitoring their food and exercise. Routines and Rituals Any reference to the routines and rituals to 33 maintain or continue weight loss Vitamins Any reference to the vitamins bariatric patients 8 have to take Follow up Appointments The sequence of follow up appointments after 26 surgery Changing your whole life Any reference to changing your life in a 14 fundamental way - also any reference to the process being lifelong Tracking Food/Exercise Any formal tracking of movement or food intake 24 Listening to Body Any reference to listening to bodies hunger or 10 pain cues. Or in some cases the lack of being in touch with those cues. Early Rapid Weight Loss Any reference to the first 1-3 years after surgery 38 when patients tend to lose a lot of weight. Later Years The period after those first few years when 53 people have to focus on maintaining. Or losing some of the weight they have begun to gain back. Losing bariatric symptoms Losing the symptoms that kept you from eating 21

234

Eating More/Weight Gain Any reference to eating more or gaining weight 37 now that a patient is further out. Goals Any reference to a person’s goals with this 79 surgery. Set Point Theory Any reference to set point theory 1 Past Weight Any reference to returning to a pervious weight 21 or seeking to return to a previous weight. Health Anything relating to health or the physical 127 condition of a person Health Appearance Any reference to appearing healthy or sick 39

Also includes codes where people switch back and forth between talking about health and appearance issues Feeling Healthier/Better Any reference to just feeling better 8 Quality of Life Any reference to quality of life as it relates to 17 health Mobility, Pain, Fitness Any reference to mobility issues or changes in 171 mobility. This includes references to physical fitness Future Health Any speculation about future health. Either 52 future death, future illness, that would have/ could happen without the surgery. Pre-Surgery Health References to health before surgery 9 Post-Surgery Health Any reference to health improving after surgery 55 Complications This code is for extra time spent in the hospital 107 or returning to the hospital due to complications - this can also include infections and things treated outpatient. Illness and Disability Any reference to illness or disability - related to 146 obesity or not No Health Issues Any reference to not having the additional 10 chronic illness issues many patients face.

Expanding this to include data which suggests a person did not have an illness identity (even with chronic illness) Fear of future health 0 Medication and Treatments Any reference to medication 111 Mental Health Any reference to mental health issues, trauma, 57 depression, anxiety, etc. Addiction Any reference to addictions - I am also including 48 references to binge eating disorder here to keep them with the codes for food addiction. Obesity/Medicalized Fat Terms Any reference to the word obesity, obese, also 143 other medicalized terms pertinent to the medicalization of fat like the BMI and overweight Personal Meaning The meaning patients attach to obesity 0

235

Mindset or Lifestyle Any reference to obesity as a set of behaviors, 11 habits, mindset, or lifestyle. Heredity/Genetics Any reference to fat being a genetic thing - or a 3 thing passed down from generation to generation Health Obesity equated with illness, feeling sick, pain 19 and mobility issues Psychological Issues Any reference to obesity as a psychological issue 4 Pain Any reference to pain as part of the meaning of 3 obesity Disease Any reference to obesity as a disease or not a 6 disease Pejorative/Stigma Any reference to the word being a pejorative (or 11 in Kim's case not a pejorative) BMI/Measures The complex relationship with the BMI 23 Changing Bodies Anything related to changes in the body or 87 responses to these changes Bariatric Symptoms References to any changes in the way the body 177 functions after bariatric surgery like dumping, constipations, pain, etc. Disciplinary Tools Any reference to these symptoms being 56 disciplinary tools Worth It Any reference to it being worth it in the end 2 Adjust Anything about adjusting to your new body and 81 how it works Cheating Things that bariatric patients refer to as cheating 6 - over eating around the bariatric restrictions Weight Gain after Surgery 60 Feelings about decision Anything on how patients feel about their 182 decision to undergo bariatric surgery Fear of gaining Any reference to the fear of gaining weight back 48 Changes in Self and Life Any reference to changing the way a patient 67 feels about themselves - such as growing more confident Fear/Hesitation Any fear or hesitation from friends or family who 44 are worried about their loved one getting surgery Body Image and Appearance Any reference to body image of appearance. I'm 203 also coding references to clothes here For Appearance Chapter These are the codes that correspond to sections 0 in my findings for appearance Age/Life course Any age-related issue - comment on why 73 Skin Any reference to lose skin from weight loss 25 Scars Scars from bariatric and cosmetic surgeries 6 Plastic Surgery Any reference to plastic surgery after having 28 bariatric surgery Clothes Any reference to clothes 72

236

New Regimens Any information about adopting new regimens 0 related to surgery Relationship with Food Any comment about their relationship with food. 237 Like emotional eating, bored eating, not having as strong a relationship post-surgery, etc. Pre-Surgery Any regimen adopted before surgery 64 Post-Surgery Any Regimen adopted after surgery 191 Moral Anything dealing with moral issues around 19 obesity - especially personal responsibility Following the Program Any reference to following the program - or not 134 Discipline This code includes any reference to discipline or 118 commitment. Whether it be punishing or rewarding behavior or any reference a participant makes to discipline or a lack thereof. Health Behaviors Any attribution of size, success, or failure to 11 health behaviors Policing behavior When a person polices a bariatric patient on 14 their behavior. Body Pain or Discomfort Any reference to bodily pain as a disciplinary 58 tool The Right Reasons This code relates to doing bariatric surgery for 30 the reasons. Usually the idea that the right reason to do this is for health, not for beauty. Stigma/Discrimination Any responses to the person that are 2 stigmatizing or discriminatory Stigma Management Any reference to managing the stigma of WLS 58 Hard Work Any reference to hard work to lose weight 4 Disclosure Any information about whether or how people 70 chose to disclose their surgery. WLS Stigma Stigma from having weight loss surgery 102 Fat Stigma Stigma or discrimination related to being fat 121 Health Underestimate Any instance where the health behaviors 3 someone has already adopted are underestimated because of a person’s size. Stigma Exist Anything about exciting fat stigma - this includes 52 feeling like a new person or growing in confidence. Also includes any references to failing to exist stigma. Everyone is different Any reference to how everyone's experiences 18 with WLS are not the same. Reference to my body Any reference to my body in the interview 12 Also relevant to methods Anything else that seems relevant to the 2 methods of this work Social Responses Anything related to social responses to surgery 9 Surprise When friends and relatives express surprise at 5 the participants decision Sexual/Romantic Attention Any reference to sexual attention or desiring 14 sexual attention.

237

Spouse/Family Habits Any information about spouses or family 45 members eating habits impacting bariatric patients or vice versa Negative Responses Any reference to negative responses or reactions 20 from other people to surgery or weight loss. Don't get it Any reference to the fact that most people don't 9 get it. It being either being fat or going through bariatric surgery. Talking about it too much Any reference to annoying other people or 2 worrying about annoying other people with bariatric surgery talk. Sabotage Any reference to people sabotaging bariatric 4 patients progress Ending Relationship Any reference to divorce or ending a relationship 6 after bariatric surgery - usually if they two are related or causal. Jealousy/Envy Any reference to friends or family being jealous 20 or envious Positive Reactions Any reference to positive reactions with WLS. 38 Curiosity Any reference to people being curious about 5 bariatric surgery Support Any reference to supportive, encouraging, or 6 helpful responses towards weight loss surgery Other Bariatric Patients Any reference to seeking support or information 151 from other bariatric patients Online Community Any reference to getting or seeking support 44 online Friends and Family Support provided by friends and family 146 Spouses and Partners any reference to support provided (or not 75 provided) by spouses or partners Clinic-Hospital Staff Support provided by clinic staff 128 Support Groups Any reference to the support groups at Summa 16 Health Care Anything relating to medical institutions, 4 appointments, quality of care, or any other health care related discussion Information Anything about the information provided for 10 patients by clinic staff Online Information Any reference to looking up information on the 1 internet. Not necessarily the support groups or forums. Doctors and Staff Anything pertaining to the doctors or staff. How 6 patients feel about these people. Mental health care Any reference to mental health care like 4 counseling or seeing a mental health care worker, or taking medication for a mental issue. Medical Authority Any instance of medical authority. Including 33 using medical authority as a form of credibility or acquiescing to medical authority Quality of Care Any reference to the quality of care at Summa 143

238

Suggestions for Improvement Any suggestions patients have for improving 13 Summa's program Other Bariatric Centers Any reference to another (not Summa) Bariatric 43 Clinic. Barriers and Enablers Any barrier or issue participants faced following 102 the prescribed regimes or making it to appointments. Also, things that enabled the process. Both of these include factors like time, distance, health issues, anything that helps or inhibits bariatric weight loss. "Underlying Issues" Referring to underlying mental health or other 1 issues that cause weight gain or prevent success. Distance Any reference to distance being an issue 4 Time Any reference to time being an issue to 10 accessing or achieving bariatric results Cost/Insurance Any reference to the cost of the surgery. 109

I know this is a weird place for this. It's both a barrier and an enabler. Fits in with medicalization theory. Other Health Condition Health conditions which prevent full compliance 77 with exercise or diet regimes or make completing these regimens more difficult. Caring for others Ways in which care obligations to others may 55 interfere with getting surgery or following prescribed plans

239